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A George Awad
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Lieuwe de Haan, Jules Lavalaye, Marion van Bruggen, Lonneke van Nimwegen, Jan Booij, Therese van Amelsvoort, Don Linszen
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Beliefs About Schizophrenia in Italy: A Comparative Nationwide Survey of the General Public, Mental Health Professionals, and Patients' Relatives
Lorenza Magliano, Andrea Fiorillo, Corrado De Rosa, Claudio Malangone, Mario Maj
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Personal Therapy for Schizophrenia and Related Disorders
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Original Research

Beliefs About Schizophrenia in Italy: A Comparative Nationwide Survey of the General Public, Mental Health Professionals, and Patients’ Relatives

Lorenza Magliano, MD, PhD¹, Andrea Fiorillo, MD², Corrado De Rosa, MD², Claudio Malangone, MD, PhD², Mario Maj, MD, PhD³

The opinions of the general public, patients’ relatives, and health professionals regarding the causes, treatments, and psychosocial consequences of schizophrenia can influence its detection and outcome (1–4). Lay people and patients’ relatives mainly believe that this mental disorder is caused by socioenvironmental or psychological factors (5–12), while mental health professionals generally adhere to a multifactorial causal model (13,14). There are remarkable differences among the opinions expressed by these groups in reference to treatments. While patients’ relatives usually acknowledge the positive impact of antipsychotic drugs on the clinical outcome of schizophrenia (15), members of the general public often believe that these drugs are ineffective (5,16).

Acceptance of those with mental illness within the community has been found to be significantly related to previous experience with them, to a high level of education, and to cultural factors (1,17–22). Conversely, social exclusion of those with mental illness has been found to be significantly higher among people who are not well-informed about mental disorders and among those of conservative beliefs (23). Moreover, lower tolerance has been found among people who believe that mental disorders involve high risks of social dangerousness and violence (17,23–25).

In Italy, where psychiatry has a long history of community treatments, a study was conducted 10 years after the promulgation of the 1978 psychiatric reform law. This study found that the general public held negative attitudes toward those with mental illness (26).

In the last 10 years, the phase of closing psychiatric hospitals was completed, and community mental health facilities have been established all over the country (27,28)—a process that is likely to have changed the attitudes of Italians about mental disorders and, in particular, about schizophrenia.

In 1998, the Department of Psychiatry of the University of Naples SUN promoted a national study on the family and social context of schizophrenia within the framework of the National Project for Mental Health launched by the Ministry of Health (29–30). In that study, most relatives agreed that patients should have the right to vote, but they were more conservative regarding affective rights. Professionals and nurses working in southern Italy tended to be more pessimistic about psychosocial consequences of schizophrenia.

In this study, we compared beliefs about the causes, treatments, and psychosocial consequences of schizophrenia. Our sample included 714 lay respondents, 465 mental health professionals, and 709 patients’ relatives recruited in 30 randomly selected regions of Italy.

We tested whether several factors influenced beliefs about these topics. First, we investigated the impact of belonging to a particular sample group. In particular, we anticipated that professionals would have the most positive attitudes toward schizophrenia, followed by relatives; moreover, we predicted that the public would share with relatives, but not with professionals, their beliefs about factors involved in the development of this mental disorder. Second, we investigated the effect of acknowledging a diagnosis of schizophrenia. In particular, we anticipated that awareness of this diagnosis would be associated with more pessimistic beliefs about social and personal limitations deriving from the disorder. Third, we investigated sociodemographic variables. Here, we anticipated that younger and more highly educated respondents would more frequently acknowledge patients’ civil rights and social competence.

Materials and Methods

We carried out the study in 30 Italian geographic areas, which we randomly selected after taking into account their location and population density: 10 of the areas were located in northern Italy (3 in areas with more than 100 000 inhabitants, 3 in areas with 25 000 to 100 000 inhabitants, and 4 in areas with fewer than 100 000 inhabitants), 10 were located in central Italy (with the same distribution as the northern area), and 10 in southern Italy (with the same distribution). In each selected area, we involved the mental health centre and a general practitioner (GP) unit randomly selected from among those with at least 500 clients.

The study population included the following:

• Twenty-five persons consecutively recruited in each participating GP unit. They were invited to take part in the study if they were aged between 18 and 70 years, had lived in the selected area for at least 2 years, were not relatives of another client recruited in the study, did not suffer from a long-term physical or mental illness, and did not live with a relative suffering from a long-term physical or mental illness.

• All the professionals who had been working in the local mental health centre for at least 1 year at the time of the assessment.

• Key relatives (that is, those relatives who had spent the most hours in contact with the patients during the last year) of the first 25 consecutively admitted subjects who had a DSM-IV diagnosis of schizophrenia and who had attended the local mental health centre for at least 6 months. We asked key relatives to participate in the project if they were aged between 18 and 70 years, had no history of psychosis or other major mental disorder requiring treatment, and did not live with persons suffering from chronic physical or psychiatric illness other than the patient.

The study sample comprised 714 lay respondents (257 men and 457 women; mean age 41.8 years, SD 14.2 years; 38% single; 66% employed; 15% with primary school degree, 30% with secondary school degree, 44% with high school degree, and 11% with university degree), 465 professionals (195 men and 270 women; mean age 43.5 years, SD 7.9 years; 32% single; 2% with primary school degree, 13% with secondary school degree, 36% with high school or professional degree, and 49% with university degree; 43% nurses, 25% psychiatrists, 11% psychologists and sociologists, 9% social workers, 7% occupational therapists, and 5% auxiliary and administrative personnel), and 709 key relatives (205 men and 504 women; mean age 57.1 years, SD 12.6 years; 66% married; 28% employed; 54% with primary school degree, 21% with secondary school degree, 18% with high school degree, and 7% with university degree).

The 3 samples were statistically different in terms of sex (c² = 20.8, df 2, P < 0.0001), educational level (c² = 735.1, df 6, P < 0.0001), and age (F_{2, 1847} = 337.0, P < 0.0001).

Compared with the general population, we found the lay- respondent sample to include more female (general population, 52%; c² = 40.7, df 1, P < 0.0001) and highly educated persons (22% with primary school degree, 35% with secondary school degree, 33% with high school or professional degree, and 10% with university degree; c² = 47.9, df 3, P < 0.0001).

Six GPs (21%) refused to participate and were replaced with other GPs randomly selected in the same area. Respondents who did not agree to participate in the study were as follows: 11/725 lay respondents (1.5%), 24/489 professionals (5%), and 41/750 families (5.5%).

Assessment Procedures
Information on respondents’ sociodemographic characteristics was collected with an ad hoc schedule. Each respondent was asked to fill in the self-reported Questionnaire on the Opinions About Mental Illness (QO) (31) in the appropriate version (see Instrument Description).

Instrument Description
The QO (31) is a self-report instrument exploring beliefs about 1) the causes of schizophrenia (Causes subscale); 2) the effectiveness of available treatments for this disorder and patients’ right to be informed (Treatments subscale); 3) the political, social, and affective rights of patients with schizophrenia (Patients’Civil Rights subscale); 4) patients’ ability to perform social and occupational roles (Patients’ Social Functioning subscale). Items of the Treatments and Patients' Social Functioning subscales are rated on a 3-point scale, where 1 = not true and 3 = completely true. The questionnaire is available in General Public (QO-PG), Professional (QO-P), and Family (QO-F) versions. The QO-GP and the QO-P include a case vignette describing a patient who met the ICD-10 criteria for schizophrenia. In filling in the questionnaire, professionals and lay respondents were asked to refer to people with problems like those described in the case vignette, while relatives were asked to refer to people with problems like those of their ill family member. The questionnaire never mentions schizophrenia.

The psychometric properties of the QO have been formally tested and found to be satisfactory (interrater reliability is as follows: Cohen’s kappa coefficient was from 0.50 to 1 for 74% of the items; Cronbach alpha coefficient performed on the 4 subscales ranged between 0.42 and 0.72; and factor analysis accounted for 73% of total variance).

Statistical Analysis
We used chi-square and analysis of variance, as appropriate, to test differences in nominal and ordinal variables among the 3 samples.

We used Kruskal–Wallis analysis of variance to test differences in QO items among the 3 samples. We computed regression analyses to investigate the simultaneous effects of several variables on respondent beliefs about patients’ social competence and civil rights. The variables were as follows: sociodemographic variables (specifically, sex, age, and educational level), recognition of schizophrenia, beliefs about treatment of mental disorders (according to the QO treatments subscale), and population (that is, lay respondents vs professionals vs relatives). The level of statistical significance was set at 0.01 for univariate analyses and at 0.05 for multivariate analyses.

Results

Recognition of Schizophrenia and Beliefs About Its Causes
Among the general public and professional samples, 21% and 74%, respectively, identified schizophrenia in the case vignette. Among key relatives, 73% acknowledged that psychiatrists had given a diagnosis of schizophrenia to their mentally ill family members.

Although the general public and professionals held similar opinions about the factors involved in the development of schizophrenia (Table 1), the general public more frequently cited psychological trauma, stress, and incorrect therapy (c² = 9.8, df 1, P < 0.01; c² = 16.6, df 1, P < 0.0001; c² = 21.0, df 1, P < 0.0001), while professionals more frequently mentioned heredity (c² = 30.5, df 1, P < 0.0001).

Sixty-one percent of lay respondents, 73% of professionals, and 25% of relatives believed that the condition described in the case vignette was caused by both psychological and biological factors, while 34% of lay respondents, 20% of professionals and 68% of relatives mentioned psychosocial factors only (c² = 305.8, df 4, P < 0.0001).

Opinions on Outcome, Possibility of Treatment, and Right to Information
Concerning treatments, the lay respondents’ beliefs were more similar to those expressed by professionals than to those reported by relatives. Mean scores on the QO Treatments subscale were as follows: lay respondents 2.4 (SD 0.3), professionals 2.4 (SD 0.2), relatives 2.3 (SD 0.3); F_{2, 1879} = 19.1, P < 0.0001).

While 25% of the lay respondents and 28% of professionals were totally convinced of the usefulness of drugs to treat the disorder, this percentage was significantly higher among relatives (48%; Kruskal–Wallis test = 72.7, df 2, P < 0.0001) (Table 2). However, the lay respondents’ beliefs concerning the usefulness of psychosocial interventions differed from those of professionals and relatives; 58% of the lay respondents acknowledged their usefulness, compared with 44% and 46% in the other 2 samples, respectively (Kruskal–Wallis test = 25.1, df 2, P < 0.0001). Belief in the patients’ possible complete recovery was admitted by 35% of lay respondents, compared with 2% of professionals and 17% of relatives (Kruskal–Wallis test = 259.3, df 2, P < 0.0001).

Opinions About Patients’ Social Competence
On average, lay respondents’ opinions about patients’ social competence were more similar to those observed among professionals than to those reported by relatives. Mean scores on the QO Social Functioning subscale were as follows: lay respondents 2.1 (SD 0.4), professionals 2.1 (SD 0.3), and relatives 2.0 (SD 0.4); F_2,1876 = 4.4, P < 0.01).

The general public sample shared with professionals opinions about the capability of patients to work as other people and to work as babysitters (Table 3). Moreover, the public and professionals showed similar beliefs about the recognizability of psychiatric patients and the similarity of psychiatric hospitals to prisons.

The lay respondents differed significantly from the other 2 samples concerning beliefs about the unpredictability of patients with schizophrenia and the opportunity to admit them to asylums.

Regression analysis revealed that acknowledgement of patients’ social competence was higher among younger respondents (β value = –0.06, P < 0.05), with higher levels of education (β value: 0.16, P < 0.0001), who did not recognize the presence of schizophrenia (β value = –0.22, P < 0.0001), who believed that mental disorders can be successfully treated (β value = 0.26, P < 0.0001), and who were not professionals (β value = –0.13, P < 0.0001) or lay people (β value = –0.14, P < 0.0001) (F_7,1746 = 39.7, P < 0.0001; adjusted R² = 0.13).

Opinions About Patients’ Civil Rights
The lay respondents’ beliefs about patients’ civil rights tended to be more similar to those expressed by professionals than to those reported by relatives. Mean scores on the QO Patients’ Civil Rights subscale were as follows: lay respondents 2.2 (SD 0.5), professionals 2.2 (SD 0.4), and relatives 1.9 (SD 0.5); F_{2, 1873} = 85.8, P < 0.0001.

The general public and professionals had similar opinions on topics such as the need for a special divorce procedure if the partner has schizophrenia and the opportunity for these patients to get married (Table 4); 19% of the general public, 17% of professionals, and 49% of relatives were completely convinced that these patients should not have children (Kruskal–Wallis test = 87.1, df 2, P < 0.0001).

The only topic on which the 3 samples expressed similar opinions was that concerning the patients’ right to vote. Regression analysis revealed that patients’ civil rights were more frequently acknowledged by respondents who were younger (β value = –0.20, P < 0.0001), with higher levels of education (β value = 0.06, P < 0.05), who did not recognize the presence of schizophrenia (β value = –0.14, P < 0.0001), who firmly believed that mental disorders could be treated successfully (β value = 0.20, P < 0.0001), and who were professionals (β value = 0.11, P < 0.0001) or lay people (β value = 0.7, P < 0.05) (F_{7, 1744} = 54.2, P < 0.0001; adjusted R² = 0.17).

Discussion

This is the first Italian study to systematically compare beliefs about schizophrenia in representative samples of different target populations. Although the study addresses a worldwide problem, its results are likely influenced by the national mental health policy. Further studies are needed to compare the Italian situation with that of countries having different mental heath care organizations.

Most lay respondents recognized in the vignette a pathological status and acknowledged that it required psychiatric treatment, although only 21% named it schizophrenia. This percentage, significantly lower than that found among professionals and relatives, is probably influenced by the stigma still associated with the diagnosis of schizophrenia and by lack of information on this mental disorder among the general public (3,23). Our findings on the general public’s lack of knowledge about symptoms of schizophrenia, its causes, and its treatments are consistent with those reported in other studies (2,32).

The general public and professionals share a biopsychosocial model of schizophrenia, while relatives more frequently adhere to a psychological model. The low importance given to biological factors by relatives is probably in part related to strategies they adopt to cope with feelings of guilt associated with a genetic transmission of the illness (33).

It should also be outlined that the comparison between relatives’ beliefs and those expressed by professionals and the general public is somewhat problematic. The latter 2 groups tend to think about the causes of schizophrenia in general terms, while relatives think about the specific causes of the illness of their family member. This problem can be only partly overcome by the use of case vignettes. Conversely, studies comparing attitudes in different populations toward persons with mental illness can help to clarify factors influencing patients’ social inclusion.

Among the general public, 35% believe that patients with schizophrenia can recover and that there is little to do for these patients, apart from helping them to live in a peaceful environment. These findings reflect public wariness toward medical treatment and are supported by the limited importance this sample assigned to drugs and the high significance attributed to family and social support as therapeutic factors.

That the public clearly favours nonpharmacologic inter- ventions is probably in part owing to inadequate and misleading information on antipsychotics and the common attribution of benzodiazepine-like side effects to antipsychotics, which supports public scepticism about their efficacy (34).

The relatively high social acceptance of patients among all 3 samples is probably related to the availability of rehabilitative and social interventions (27,28)—a hypothesis supported by the fact that this study shows a significantly higher percentage of lay respondents (26%; c² = 16.27, df 1, P < 0.0001) who totally believe that patients with psychosis behave and are able to work as other people, compared with the percentage found in the 1988 study (2%; c² = 107.04, df 1, P < 0.00001) (26). However, the comparison of these data with those of the 1988 study should be considered only partly appropriate and should be interpreted with some reservations. The 1988 study did not use a case vignette depicting a person suffering from schizophrenia as a stimulus for respondents, who were asked to express their beliefs about mentally ill people in general. Further, in the present study, a higher percentage of lay respondents than that reported in other surveys believe that persons with schizophrenia can get married (21).

The effects of 20 years of mental health policy and media campaigns supporting psychiatric reform are highlighted by the low percentage of respondents who completely agree with the usefulness of admitting psychiatric patients to asylums. This percentage is significantly lower than that found in 1988, when 62% of lay respondents declared themselves in favour of admission to asylums (c² = 1555.60, df 1, P < 0.00001).

Although the case vignette did not refer explicitly to bizarre or aggressive behaviours, 85% of lay respondents reported the belief that psychiatric patients are unpredictable. This finding is consistent with that reported by Crisp and others, who found that 77% of lay respondents viewed people with schizophrenia as unpredictable (22). In addition, the percentage of lay respondents who are completely convinced of the unpredictability of these patients increased from 24% in 1988 to 35% in the current study (c² = 19.7, df 1, P < 0.00001). This increase is probably related to media coverage of criminal acts committed by psychiatric patients (35,36) and also to the limited diffusion of interventions to manage antisocial behaviours. Conversely, the low percentage of professionals and relatives who believe that those with mental illness are unpredictable is probably related to their direct involvement with patients and the awareness that unpredictable behaviours mainly occur in acute phases of schizophrenia.

Acknowledgement of patients’ civil and affective rights was higher among the general public and professionals than among relatives. This discrepancy could be owing to the burden of care sustained by relatives with limited professional support (37). Nevertheless, 71% of lay respondents acknowledged patients’ political rights, compared with 29% in the 1988 study (c² = 227.9, df 1, P < 0.00001).

The results of this study suggest the need for action in 3 areas. First, it is necessary to inform the general public about the main clinical characteristics of schizophrenia and about the efficacy of available treatments. Second, it is necessary to carry out sensitization campaigns that will raise awareness of discrimination against mentally ill patients by disseminating information on risks of dangerousness in different psychiatric disorders and on patients’ potential to achieve their social and work goals. Third, it is necessary to reduce the existing gap in the beliefs of relatives, professionals, and general public concerning patients’ affective and civil rights by implementing community mental health policies and providing supportive interventions to patients’ families.

Funding and Support

This study was supported by a grant from the National Mental Health Project, National Institute of Health, Italy (grant # 96/Q/T/38).

Acknowledgement

We are grateful to Prof M Angermeyer and Dr I Levav for their extremely useful comments on the initial draft of the manuscript. We thank Prof M D’Albora Calabrese and Dr J Gates for their linguistic help in preparing the text. We are grateful to the general public, professionals, and relatives who gave us their time.

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Author(s)

Manuscript received July 2003, revised, and accepted August 2003.

1. Associate Professor, Department of Psychiatry, University of Naples, SUN, Naples, Italy.

2. Staff Psychiatrist, Department of Psychiatry, University of Naples, SUN, Naples, Italy.

3. Full Professor, Department of Psychiatry, University of Naples, SUN, Naples, Italy.

Address for correspondence: Dr L Magliano, Department of Psychiatry, University of Naples SUN, Largo Madonna delle Grazie, 80138 Naples, Italy

e-mail: lorenza.magliano@unina2.it

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