This article was downloaded by: On: 24 November 2010 Access details: Access Details: Free Access Publisher Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 3741 Mortimer Street, London W1T 3JH, UK
AIDS Care
Publication details, including instructions for authors and subscription information: http://www.informaworld.com/smpp/title~content=t713403300
Perspectives towards mental illness in people living with HIV/AIDS in South Africa Katherine R. Sorsdahla; Sumaya Malla; Dan J. Steina; John A. Joskaa a Department of Psychiatry & Mental Health, University of Cape Town, J-block, Groote Schuur Hospital, Cape Town, South Africa First published on: 16 July 2010
To cite this Article Sorsdahl, Katherine R. , Mall, Sumaya , Stein, Dan J. and Joska, John A.(2010) 'Perspectives towards
mental illness in people living with HIV/AIDS in South Africa', AIDS Care, 22: 11, 1418 — 1427, First published on: 16 July 2010 (iFirst) To link to this Article: DOI: 10.1080/09540121003758655 URL: http://dx.doi.org/10.1080/09540121003758655
PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf This article may be used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
AIDS Care Vol. 22, No. 11, November 2010, 1418 1427
Perspectives towards mental illness in people living with HIV/AIDS in South Africa Katherine R. Sorsdahl*, Sumaya Mall, Dan J. Stein and John A. Joska Department of Psychiatry & Mental Health, University of Cape Town, J-block, Groote Schuur Hospital, Observatory, Cape Town 7925, South Africa (Received 4 December 2009; final version received 3 March 2010)
Downloaded At: 10:57 24 November 2010
Psychiatric disorders are more common in people living with HIV/AIDS (PLWHA) than in the general population and they exert a significant effect on many health-related outcomes. Low levels of mental health literacy and stigma may contribute to delayed treatment seeking and poorer outcomes. A convenience sample of 400 HIV-positive respondents were selected from three health clinics in Cape Town. Respondents’ mental health literacy and attitudes towards psychiatric disorders were investigated. Psychiatric disorders were viewed as stressrelated 70 91% of the time. Seeking help from a medical professional was often endorsed as an effective treatment option, while taking medication was rarely endorsed. Respondents held negative attitudes towards people with psychiatric disorders. In particular, people with substance abuse and PTSD were stigmatised more than those with depression and schizophrenia. The understanding of the psychobiological nature of psychiatric disorders and of existing effective treatments in PLWHA in South Africa is limited. Interventions designed to increase mental health literacy and reduce the stigma associated with psychiatric disorders may increase the likelihood of PLWHA seeking treatment should they suffer from these conditions.
Keywords: mental health; health literacy; stigma; acquired immunodeficiency syndrome; South Africa
Introduction Psychiatric disorders are not only more common in people living with HIV/AIDS (PLWHA) than in the general population, but they exert a significant effect on many health-related outcomes. According to a meta-analysis, PLWHA are twice as likely to suffer from depression than the general population (Ciesla & Roberts, 2001). Furthermore, psychiatric disorders such as depression have been consistently linked with lowered likelihood of receiving HAART (Fairfield, Libman, Davis, & Eisenberg, 1999; Turner, Laine, Cosler, & Hauck, 2003), poorer medication adherence (Ammassari et al., 2002; Catz, Kelly, & Bogart, 2000; Spire et al., 2002), and if untreated, greater mortality (Cook et al., 2004; Ickovics et al., 2001). In addition, psychopathology in HIV-positive populations have been associated with decreased quality of life (Sherbourne et al., 2000) and may increase highrisk behaviours for the further transmission of HIV (Brown et al., 2006; Smit et al., 2006). Despite evidence that pharmacotherapy and psychotherapeutic interventions are helpful for comorbid psychiatric disorders in PLWHA, there are numerous barriers that contribute to inadequate care. These include societal, institutional and individual factors (Collins, Holman, Freeman, & Patel, 2006).
*Corresponding author. Email: katherine.sorsdahl@uct.ac.za ISSN 0954-0121 print/ISSN 1360-0451 online # 2010 Taylor & Francis DOI: 10.1080/09540121003758655 http://www.informaworld.com
Individual level factors include patients’ own knowledge and attitudes towards psychiatric disorders (Ganasen et al., 2008). When knowledge about psychiatric disorders (or mental health literacy) is decreased, and stigma associated with such conditions is high, a lower rate of help-seeking is often reported (Angermeyer, Beck, Dietrich, & Holzinger, 2004; Jorm et al., 1997). The term mental health literacy is defined as the ‘‘knowledge and beliefs about mental illness that aid their recognition, management or prevention’’ (Jorm et al., 1997, p. 183). Correct recognition of disorders has the potential to influence help-seeking behaviour and has clear implications for adherence to treatment (Jorm et al., 1997; Wright, Jorm, Harris, & McGorry, 2007). Although a number of studies have been conducted in the developed world assessing mental health literacy (Angermeyer & Dietrich, 2006), little work has been done in the developing world (Hugo, Boshoff, Traut, Zungu-Dirwayi, & Stein, 2003; Mbanga et al., 2002). In one survey in South Africa, 667 participants were presented with a vignette of depression, schizophrenia, panic disorder or substance use and their beliefs and knowledge concerning the vignette was elicited. Most participants reported that the problems described in the vignettes were stress related (76.8%), and that talking about the
Downloaded At: 10:57 24 November 2010
AIDS Care problem (84.8%) and psychotherapy (69.7%) were the preferred treatment options. In addition, 54% reported that medication was not the best treatment option available as this was habit-forming, not reliable at preventing relapse and could only calm patients down (Hugo et al., 2003). The majority of the literature available investigating mental health literacy has been conducted primarily on the general population, rather than specific groups who may be more at risk for a mental disorder. High levels of psychiatric disorders have been described amongst specific populations groups, such as lesbian/gay/bisexual populations (Cochran, 2001; Gilman et al., 2001), illicit drug users (Hall, Teesson, Lynskey & Degenhardt, 1999) and PLWHA (Ciesla & Roberts, 2001). Stigmatisation of individuals with psychiatric disorders is widespread and serves as a major barrier to treatment. This ‘‘public stigma’’ has been wellestablished in the literature (Green, McCormick, Walkley & Taylor, 1987; Taylor & Dear, 1981). Individuals who have suffered or are suffering from a psychiatric disorder are often viewed as being unpredictable, tense and dangerous, worthless, delicate, slow, weak, dirty and foolish. Due to this public stigma, life opportunities such as employment, suitable accommodation and satisfactory health care of the mentally ill may be negatively affected (Bordieri & Drehmer, 1986; Farina & Felner, 1973; Mbanga et al., 2002). More recently, studies investigating internalized stigma are emerging in the literature (Dinos, Stevens, Serfaty, Weich, & King, 2004; Link, Struening, Neese-Tood, Asmussen, & Phelan, 2001; Watson, Corrigan, Larson & Sells, 2007). The literature reveals that patients with a mental illness who ‘‘self stigmatize’’ struggle to adjust socially (Perlick et al., 2001) and often report a lower satisfaction with life (Rosenfield, 1997), than individuals without a mental illness. Internalised stigma may also prevent some from seeking professional help (Robertson & Donnermeyer, 1997) and render others less likely to adhere to treatment (Sirey et al., 2001). Very few studies have been conducted in South Africa investigating the perspectives of patients towards psychiatric disorders (Botha, Koen, & Niehaus, 2006) and community members towards the mentally ill (Mbanga et al., 2002), and none focusing specifically on the views of HIV-positive patients. Stigma related to HIV has been shown to lead to a variety of negative effects on health behaviours (Holzemer & Uys, 2004; Simbayi et al., 2007). Individual knowledge and attitudes may underlie much of the experience of stigma. It is not clear whether PLWHA, who are at higher risk of developing mental disorders, may not access mental
1419
health care through an inability to recognise and report symptoms of mental disorders in themselves. These disorders may carry an independent stigmatization of their own. We aimed to investigate the attitudes of PLWHA in South Africa towards people with psychiatric disorders, as well as mental health literacy in relation to four major disorders (depression, schizophrenia, PTSD and substance abuse). We hypothesised that PLWHA will report low mental health literacy and varying levels of stigma dependent on the type of disorder presented. Methods Participants A convenience sample of 400 HIV-positive respondents was selected from three health clinics in the Cape Town area (Woodstock, Crossroads & Delft). These research sites were chosen as they are part of an existing clinical research infra-structure, and also have separate sections for HIV treatment and care which facilitates convenient recruiting of potential participants. All participants were above 18 years of age. Measures Mental health literacy The present study utilised a modified version of a questionnaire developed by Hugo et al. (2003) which was in turn based on that of Angermeyer and Matschinger (1994). Modifications included the addition of traditional healers and religious advisors as potential sources of treatment and ‘‘thinking too much’’ as a possible cause of psychiatric disorders. Each participant was presented with two vignettes. The vignettes depict DSM-IV symptoms of depression, PTSD, substance abuse disorders and schizophrenia due to their particular relevance for PLWHA. For example, the depression vignette read as follows: ‘‘Brenda started feeling increasingly sad after her sister died in a motorcar accident. Of course, the whole family had been affected by this tragic loss, but Brenda’s sadness seemed to last the longest. Some six months after her sister’s death, she was still unable to keep thoughts about this loss out of her mind. She continuously questioned the value of life. She found that she had difficulty falling asleep, lost 10 kg in weight, had very little energy, and she had trouble concentrating. At work, she found herself crying without reason’’. Each participant was randomly assigned using a coin toss to receive version A of the questionnaire (depression and schizophrenia) or version B (PTSD and substance abuse). Immediately after reading each
1420
K.R. Sorsdahl et al.
vignette, respondents were asked to rate on the fivepoint scale a series of questions about the aetiology and treatment of the symptoms.
Research Ethics Committee of the Health Sciences Faculty of the University of Cape Town.
Downloaded At: 10:57 24 November 2010
Analysis The ‘‘Community Attitudes to Mental Illness’’ scale (CAMI) The Community Attitudes to Mental Illness scale (CAMI) measures attitudes in the general population about mental illness and has 40 items covering four sub-scales including: Authoritarianism (refers to a view of the mentally ill person as someone inferior who requires coercive handling), Benevolence (corresponds to a paternalistic and sympathetic view of the mentally ill), Social Restrictiveness (refers to the belief that the mentally ill are a threat to society and should be avoided), Community Mental Health Ideology (concerns the acceptance of mental health services and mentally ill patients in the community) (Taylor & Dear, 1981). Psychometric properties of this scale were tested and found to be adequate in several samples in the USA and Canada. Higher scores on these sub-scales equate to more stigma towards the mentally ill.
Data were analysed using Stata Version 10.0 (Stata Corporation, College Station, USA) and the Statistical Package for the Social Sciences (SPSS) 17.0. The sample was described and differences in responses to the aetiology and treatment were examined using chi-square calculations. Analysis of variance was calculated to determine any difference between the respondent’s attitudes towards the mental disorders depicted in the vignettes. The distribution of the vignette scores was tested for normality using the Shapiro Wilk test. The scores were not normally distributed, and therefore were analysed as matched pairs (Groups 1 and 2) using the Wilcoxon Signed Rank test. Finally, a multiple logistic regression model to examine the independent association between demographic variables and whether or not the respondents could identify the vignette as a psychiatric disorder was developed. Results
Attribution Questionnaire Short-Form (AQ-SF) This scale was given after each vignette. Responses are coded on nine-point opinion scales (ranging from ‘‘not at all’’ to ‘‘very much’’). The Attribution Questionnaires were developed to address nine stereotypes about people with mental illness. This includes blame, anger, pity, help, dangerousness, fear, avoidance, segregation and coercion. The factor structure and reliability of the original Attribution Questionnaire have been validated in two confirmatory factor analyses (Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003). Procedure Potential participants were approached in the waiting rooms at the various clinics by a research assistant trained to administer the questionnaire in both Xhosa and English. Prior to the interview, each participant was informed about the confidentiality and anonymity of the process. Participation was voluntary, as was withdrawal from the study. Consent was then obtained for participation in the study. Half of the sample was given the vignettes on depression and substance abuse (Group 1) and the other half on schizophrenia and PTSD (Group 2). Following completion of the interview each participant was given a R50 (approximately US$6) grocery voucher for their time. The study was approved by the
Details of demographic characteristics of the sample are provided in Table 1. A majority of the participants were female (78.5%), Xhosa speaking (91%) and unemployed (89%). Twenty-three per cent of the sample was diagnosed with HIV less than a year ago, 19% between one and two years ago, 35% between three and five years ago and 24% were diagnosed more than six years ago. Participants decided to get tested for HIV for a number of reasons. The majority of the respondents decided to get tested for HIV because they were pregnant (n 94, 24%), or because they had been encouraged to get tested after a diagnosis of TB (n 84, 21%) or another physical illness (n 79, 20%). Forty-three respondents (11%) decided to get tested because their partner was either HIV positive or died from HIV. Mental health literacy Overall, only 23% of the respondents reported that the case study presented to them was typical of a mental illness, despite descriptions in the vignettes being constructed to align with DSM-IV criteria for a particular psychiatric disorder. Additionally, 11% believed the descriptions were of someone with a ‘‘normal response’’ and 3% believed the behaviours were typical of a general medical condition. Almost all of the respondents (86%) reported that the behaviour described in the vignettes was typical of a weak character. There was a significant difference in
AIDS Care
1421
Downloaded At: 10:57 24 November 2010
Table 1. Demographic characteristics of the sample. Version A% (n)
Version B & (n)
35.24 (34.4 36.0) 23.0 (46) 51.5 (103) 20.5 (41) 5.0 (10)
33.17 (32.3 34.0) 37.5 (75) 42.0 (84) 14.5 (29) 6.0 (12)
0.011
Age Mean 18 29 30 39 40 49 50
34.2 30.2 56.8 17.5 5.5
Gender Male Female
21.5 (85) 78.5 (314)
25.5 (51) 74.5 (149)
17.5 (35) 82.5 (165)
0.051
Home language Xhosa Other SA language Afrikaans Other Africa language
90.8 3.0 4.8 1.5
88.0 4.5 5.0 2.5
93.5 1.5 4.5 0.5
(187) (3) (9) (1)
0.109
Education None-Grade 8 Grades 9 11 Matric
11.1 (43) 71.9 (279) 17.0 (66)
8.8 (17) 76.3 (148) 14.9 (29)
13.4 (26) 67.5 (131) 19.1 (37)
0.143
Employment Employed Unemployed
15.8 (64) 83.8 (335)
19.2 (38) 80.8 (160)
12.5 (25) 87.5 (175)
0.067
Duration of knowing their HIV Less than a year 1 or 2 years 3 5 years 6 years
22.5 18.5 35.2 23.8
23.5 15.0 36.5 25.0
21.5 22.0 34.0 22.5
0.352
Mental illness Have received treatment Thinks they have a mental illness
(33.4 35.1) (121) (187) (70) (22)
(363) (12) (19) (6)
(90) (74) (141) (95)
2.6 (10) 2.3 (9)
the extent to which disorders were considered to be a normal response (x2 51.85, df 6, pB0.001), typical of mental illness (x2 137.73, df 3, pB0.001) and typical of weak character (x2 31.68, df 3, p B 0.001). The PTSD vignette was more likely to be considered a normal response (23%), and less likely to be considered to be caused by a weak character (73%) than the other disorder vignettes (see Table 3). Substance use was more likely to be considered typical of a mental illness (53.8%) than the other disorders. In order to ascertain whether certain demographics characteristics (including gender, age & home language) had contributed to these effects, a multivariate logistic model was developed. The demographic characteristics did not contribute significantly to the model. Psychosocial stressors were reported to be the main cause of all four disorders (58 86%), followed by intra-psychic factors (35 59%), biological factors (21 38%), socialisation (9.6 28.1%), state of society
(176) (9) (10) (5)
(47) (30) (73) (50)
4.1 (8) 1.6 (3)
(43) (44) (68) (45)
1.0 (2) 3.0 (6)
0.056 0.395
(5 16%) and supernatural factors (0.5 6%; see Table 2). The cause attributed to the various mental disorders differed significantly by work difficulties (x2 44.66, df 3, pB0.001) and stress (x2 34.98, df 3, pB0.001). Schizophrenia (91%) and PTSD (86%) were more likely than the other disorders to be attributed to stress, while schizophrenia was considered more likely than the other disorders to be caused by work difficulties, and depression (60%) less likely to be caused be work difficulties. Additionally substance abuse was more likely than the other disorders to be attributed to over protective parents (x2 23.10, df 3, pB0.001), lack of parental affection (x2 15.92, df 3, p 0.001) and loss of traditional values (x2 9.14, df 3, p 0.028) than the other disorders. A number of treatment options were reported to be helpful for individuals with a mental disorder. Psychological treatments, such as seeking help from a counsellor (96 99%) or a psychiatrist (74 83%) were frequently reported. In line with these findings
1422
K.R. Sorsdahl et al.
Table 2. Mental health literacy causes of mental disorders. Depression Schizophrenia Substance abuse % Yes (n)
% Yes (n)
% Yes (n)
% Yes (n)
P-value
5.6 87.5 10.2 3.4
(11) (173) (20) (7)
4.2 89.9 13.8 2.2
(8) (170) (26) (4)
9.6 90.9 53.8 1.0
(19) (179) (106) (2)
23.1 73.3 15.4 3.1
(45) (143) (30) (6)
pB0.001 pB0.001 pB0.001 0.386
Causes of mental illness Psychosocial stress Difficulties in partner or family relationships Work difficulties Stress Thinking too much
68.7 59.6 81.3 59.3
(146) (118) (161) (67)
68.0 89.2 90.7 65.6
(132) (173) (176) (78)
71.4 71.6 68.9 57.7
(140) (139) (135) (64)
64.8 73.2 86.1 64.5
(125) (142) (167) (78)
0.525 pB0.001 pB0.001 0.536
Biological Brain disease Hereditary/genetic Weakness
30.8 (61) 20.7 (41) 22.3 (44)
38.1 (74) 25.8 (50) 25.5 (49)
35.3 (68) 27.0 (53) 26.5 (52)
32.0 (62) 21.2 (41) 23.7 (46)
0.365 0.347 0.769
Intra-psychic factors Lack of willpower Expecting too much from oneself Unconscious conflict
50.0 (99) 53.0 (105) 34.8 (69)
55.2 (107) 58.8 (114) 42.8 (83)
57.4 (112) 51.3 (100) 41.5 (81)
55.2 (107) 55.5 (107) 37.3 (72)
0.500 0.459 0.369
Socialisation Growing up in a broken home Lack of parental affection Overprotective parents
20.2 (40) 14.1 (28) 9.6 (19)
21.7 (42) 15.0 (29) 11.3 (22)
28.1 (55) 27.2 (43) 25.0 (49)
17.0 (33) 13.9 (27) 12.9 (25)
0.056 pB0.001 pB0.001
State of society Loss of traditional values in society Decay of natural ways of life Exploitation of people in industrial society
7.1 (14) 6.1 (12) 4.6 (9)
8.8 (17) 5.7 (11) 7.2 (14)
15.8 (31) 11.8 (23) 9.7 (19)
9.3 (18) 5.7 (11) 4.6 (9)
0.028 0.062 0.150
Supernatural powers Will of god Witchcraft Signs of zodiac
5.6 (11) 2.5 (5) 0.5 (1)
4.1 (8) 3.1 (6) 1.6 (3)
2.0 (4) 3.6 (7) 2.6 (5)
2.1 (4) 3.6 (7) 1.0 (2)
0.157 0.915 0.355
Behaviour Behaviour Typical of Typical of
Downloaded At: 10:57 24 November 2010
PTSD
is normal response is typical of weak character mental illness general medical problem
participating in psychotherapy (85 90%) was rated as a highly valuable resource for the individuals described in the vignettes, in addition to talking problems over with a close family member (87 94%) or close friend (84 90%). Only a few respondents reported antidepressants (3 10%) and antipsychotics (5 17%) to be helpful for the individuals described in the vignettes, and a minority felt that traditional healers (4 12%) were the best route to treatment (see Table 3). There was a significant difference across conditions in the extent to which antidepressants (x2 21.10, df 6, p 0.002), antipsychotics (x2 14.92, df 3, p 0.002) and benzodiazepines (x2 23.55, df 3, p B0.001) were endorsed. Thus, antidepressants were most commonly advocated for PTSD (15%) and depression (13%), antipsychotics were least favoured for
substance abuse (5%) and benzodiazepines were favoured most for PTSD (17%) and least for substance abuse (5%) (See Table 3). Stigma associated with mental illness On the scale of 1 5, the highest reports of stigma were for: Benevolence (m 2.61, SD 0.369) and Social Restrictiveness (m 2.55, SD 0.457), with lower levels of endorsement of Community Mental Health Ideology (m 2.43, SD 0.378) and Authoritarianism (m 2.38, SD 0.290). Mean scores and standard deviations of the items from the Attribution Questionnaire Short-Form (AQ-SF) between the depression and substance use and schizophrenia and PTSD vignettes are summarised in Table 4. In the comparison of the
AIDS Care
1423
Table 3. Mental health literacy treatment of mental disorders. Depression
Schizophrenia
Substance abuse
PTSD
p-value
% Helpful (n)
% Helpful (n)
% Helpful (n)
% Helpful (n)
% Helpful (n)
Psychological Counsellor Social worker Telephone counselling Psychiatrist Psychologist Psychotherapy (talk therapy) Hypnosis
98 (103) 84.2 (165) 65.5 (129) 73.5 (144) 86.3 (170) 85.1 (165) 11 (17)
98 (192) 82.1 (160) 66.3 (130) 81 (158) 88.3 (173) 88.5 (169) 9.6 (15)
95.9 (187) 74.1 (143) 55.7 (107) 77.3 (15) 86.6 (84) 89.7 (174) 12 (19)
99.0 (189) 83.7 (159) 71.4 (135) 83.2 (158) 92.7 (177) 90 (171) 11.1 (16)
0.235 0.04 0.013 0.098 0.181 0.41 0.76
Lifestyle Close family Close friends Naturopath Vitamins Physical activity Get out more
87.3 84.3 4.1 2.5 61.9 79.6
(172) (166) (8) (5) (120) (156)
91.8 (180) 88.3 (173) 5.2 (10) 1.0 (2) 60 (117) 80.4 (156)
89.2 (173) 84 (163) 3.1 (3) 1.5 (3) 61.5 (118) 60.4 (116)
93.7 (179) 90 (171) 2.1 (4) 1.1 (2) 63.2 (120) 82.1 (156)
0.186 0.088 0.423 0.585 0.938 p B0.001
Medical Pain relievers Antidepressants Antipsychotics Antibiotics Sleeping pills Tranquilisers Psychiatric ward Shock therapy
6.1 13.3 11.2 3.1 14.3 4.1 61.9 3.9
(12) (26) (22) (6) (28) (8) (120) (7)
4.1 (8) 8.7 (17) 11.8 (23) none 9.7 (17) 2.1 (4) 67.7 (132) 1.1 (2)
1.6 3.1 4.6 0.5 0.5 0.5 85.1 1.1
4.7 14.7 16.9 2.1 18.0 9.8 60.3 1.1
0.147 0.002 0.002 0.038 p B0.001 p B0.001 p B0.001 0.115
Downloaded At: 10:57 24 November 2010
Treatment of mental illness
Spiritual Traditional healer Spiritual or religious advisor
5.2 (10) 7.2 (14)
4.1 (8) 5.7 (11)
depression and substance use vignettes, results of subsequent repeated-measures analyses of variance for almost all the items were significant, with the exception of dangerousness (p 0.615) and
(3) (6) (9) (1) (1) (1) (165) (2)
12.3 (24) 6.7 (13)
(9) (28) (32) (4) (34) (18) (114) (2)
4.8 (9) 5.3 (10)
0.003 0.86
avoidance (p 0.050). Overall, substance use was stigmatized significantly more than depression (pB0.001). On the other hand, when comparing the schizophrenia and PTSD vignettes, only four of the
Table 4. Scores on the Attribution Questionnaire measuring feelings towards individuals with different mental disorders. Group 1 Depression
Group 2
Substance abuse
Schizophrenia
PTSD
Item
Mean
SD
Mean
SD
p-Value
Mean
SD
Mean
SD
p-Value
Pity Dangerousness Fear Blame Coercion Anger Help Segregation Avoidance Total score
6.47 2.78 4.39 3.03 3.73 3.47 6.63 2.13 2.84 35.44
1.32 1.70 2.50 1.61 2.14 1.86 2.44 1.62 1.34 6.79
4.00 2.70 3.09 6.43 5.26 6.50 6.37 2.92 3.23 40.45
2.88 1.48 1.86 2.52 2.24 2.54 2.27 1.88 1.84 7.09
B0.001 0.615 B0.001 B0.001 B0.001 B0.001 0.026 B0.001 0.050 B0.001
6.10 2.98 3.81 3.73 3.79 3.89 6.08 2.64 3.02 36.00
1.61 1.74 1.90 1.76 2.15 1.94 2.42 1.90 1.48 7.47
6.70 3.32 4.09 3.39 3.56 3.43 7.16 2.12 4.09 37.81
1.33 1.83 1.98 1.60 2.07 1.82 2.07 1.53 1.92 8.31
B0.001 0.164 0.180 0.060 0.202 0.046 B0.001 B0.001 B0.001 0.004
1424
K.R. Sorsdahl et al.
nine items were significant. Overall, the PTSD vignette was stigmatized significantly more than schizophrenia vignette (p 0.004).
Downloaded At: 10:57 24 November 2010
Discussion This study had a number of important findings. First, PLWHA in primary care are generally unable to correctly identify the presence of a mental disorder. Of all the conditions presented, participants considered substance use (alcoholism) more indicative of a psychiatric disorder. Second, respondents regarded schizophrenia as more stress related than depression. Third, treatments most likely to be endorsed included seeking help from a medical professional, such as a counsellor or psychiatrist, while taking medication was least likely to be endorsed. Fourth, substance abuse and PTSD were stigmatised more than depression and schizophrenia. In PLWHA attending primary care clinics, only 23% identified the presence of psychiatric disorders in the vignettes. Fewer still were able to name the specific disorders (6%) (data not shown). This failure to identify psychiatric disorders in others is likely to lead a failure to communicate these to health practitioners. It has been suggested that general practitioners are more likely to detect a mental disorder if the patient presents the symptoms in psychological rather than somatic terms (Kessler, Lloyd, Lewis & Gray, 1999), and if the patient explicitly raises the possibility of a mental disorder with the general practitioner (Jacob, Bhugra, Lloyd & Mann, 1998). Previous research utilising vignettes concluded that symptoms of schizophrenia are more often seen as an expression of mental illness than depressive symptoms or alcoholism (Angermeyer & Dietrich, 2006). However, the results of the present study reveal a different pattern. In the present study, substance use (alcoholism) was significantly more likely to be considered typical of mental illness, compared to the other vignettes, including schizophrenia. The most prevalent lifetime DSM-IV disorder in South Africa is alcohol abuse (11.4%; Stein et al., 2008), and respondents may well have personal experience of the disorder. Additionally, over 90% of respondents were Xhosa speaking, and the data may reflect cultural beliefs that psychosis is not necessarily a medical symptom. The finding that patients with HIV attribute mental illness to psychosocial stress more frequently than the other causes investigated in the study, is consistent with previous research on community samples (Angermeyer & Dietrich, 2006; Hugo et al., 2003). In a review of population-based attitude research in psychiatry (Angermeyer & Dietrich,
2006), the authors report that in all included studies, lay beliefs about the causes of mental disorders clearly differ from the results of psychiatric research. Psychosocial stress is more frequently cited than biological causes, although more so for depression than schizophrenia. In the present study, schizophrenia was more likely than the other disorders to be caused by work difficulties and stress. The importance of educating patients and communities regarding the psychobiological nature of psychiatric disorders lies in both de-stigmatizing the illness, as well as improving the acceptability of biological treatments. Psychological interventions (e.g., psychotherapy or counselling) were the most frequently endorsed treatment options for all the vignettes, while pharmacological treatments were least commonly endorsed. This finding is consistent with several previous studies (Angermeyer & Dietrich, 2006). There is therefore a lack of awareness of the role of pharmacotherapy in the treatment of psychiatric disorders (Adams, Awad & Thornley, 2007). Although psychotherapy is also effective in many psychiatric disorders, effective psychotherapeutic treatments are not widely available in the South African context. Finally, overall the respondents in the present study held slightly negative attitudes towards the mentally ill in terms of their group means scores on the four sub-scales of the CAMI. It is interesting that none of the CAMI sub-scale scores convey strong feelings (i.e., where x 4 or x B2), with the average scores on all the sub-scales sitting just below the halfway mark, indicating subtle negative attitudes. Although the respondents generally held paternalistic and sympathetic views of the mentally ill, as measured by the Benevolence sub-scale, they also believed that people with psychiatric disorders are a threat to society and should be avoided (Social Restrictiveness scale). However, the respondents generally did not consider a mentally ill patient to be inferior to them (Authoritarianism). Levels of stigma associated with particular disorders differed significantly. To begin with, substance abuse was stigmatised significantly more than depression. This is consistent with previous studies, which found that people with alcoholism are more frequently considered unpredictable and violent than people with depression and anxiety disorders (Angermeyer & Dietrich, 2006). However, for respondents to report higher levels of stigma towards the individual in the PTSD vignette than the schizophrenia vignette is contradictory to the available literature. Yet it is consistent with the mental health literacy reported in the present study. The PTSD vignette was associated with more pity and more
Downloaded At: 10:57 24 November 2010
AIDS Care offers of help than the other vignettes, but were also more likely to be avoided than individuals suffering with schizophrenia. The data here suggest that there is a need to increase access to mental health information and services to South Africans with HIV. To begin with, there is a need to address this very low level of mental health literacy by developing appropriate interventions for PLWHA, particularly about psychotic symptoms and the value of medication. Secondly, the strengthening of mental health care services for PLWHA in South Africa should be a priority. Although the appropriateness of mass screening has long been a controversial topic with numerous pros and cons (Mant & Fowler, 1990), PLWHA are at high risk for psychiatric disorders, are already presenting to primary health care and should be receiving an integrative approach to health care. Several limitations of this study must be considered when interpreting these findings. Firstly, due to convenience sampling, the results cannot be generalised to all PLWHA in South Africa. Secondly, the vignettes used to elicit participants’ knowledge and attitudes may provide insufficient information on the nature of these disorders. Therefore, reading a description of individual’s symptoms may not directly relate to one’s ability to recognise symptoms of psychopathology within themselves. However, despite these limitations, this study revealed that PLWHA in South Africa have limited knowledge of and negative attitudes towards individuals with psychiatric disorders. Future research should focus on assessing the effectiveness of mental health and stigma interventions specifically targeted for HIVpositive South Africans.
Acknowledgements This study was made possible by support from USAID/ PEPFAR and the Peri-Natal Health Research Institute. The views expressed in this paper do not necessarily reflect those of USAID/PEPFAR. John A. Joska has received support from the National Research Foundation, the Biological Psychiatry special interest group of the South Africa Society of Psychiatrists, the Medical Research Council of South Africa and the Faculty of Health Sciences Research Committee, University of Cape Town. Dan J. Stein has received research grants and/or consultancy honoraria from Astrazeneca, Eli-Lilly, Glaxosmithkline, Lundbeck, Orion, Pfizer, Pharmacia, Roche, Servier, Solvay, Sumitomo and Wyeth. We would like to thank Ms. Anna Grimsrud for her statistical support.
1425
Funding This paper was funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR), through USAID under the terms of Award No. 674-A-00-08-00009-00 to the Perinatal HIV Research Unit.
References Adams, C.E., Awad, G., & Thornley, B. (2007). Chlorpromazine versus placebo for schizophrenia. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD000284, doi: 10.1002/14651858.CD000284.pub2. Ammassari, A., Trotta, M.P., Muirri, R., Castelli, F., Narcisco, P., Noto, P., . . . Antinori, A. (2002). Correlates and predictors of adherence to highly active antiretroviral therapy: Overview of published literature. Journal of Acquired Immune Deficiency Syndromes, 31, S123 S127. Angermeyer, M.C., Beck, M., Dietrich, S., & Holzinger, A. (2004). The stigma of mental illness: Patients’ anticipations and experiences. International Journal of Social Psychiatry, 50, 153 162. Angermeyer, M.C., & Dietrich, S. (2006). Public beliefs about and attitudes towards people with mental illness: A review of population studies. Acta Psychiatrica Scandinavica, 113, 163 179. Angermeyer, M.C., & Matschinger, H. (1994). Lay beliefs about schizophrenic disorder: The results of a population survey in Germany. Acta Psychiatrica Scandinavica, 89, 39 45. Bordieri, J., & Drehmer, D. (1986). Hiring decisions for disabled workers: Looking at the cause. Journal of Applied Social Psychology, 16, 197 208. Botha, U.A., Koen, L., & Niehaus, D.J. (2006). Perceptions of a South African schizophrenia population with regards to community attitudes towards their illness. Social Psychiatry and Psychiatric Epidemiology, 41, 619 623. Brown, L.K., Tolou-Shams, M., Lescano, C., Houck, C., Zeidman, J., Pugatch, D., & Lourie, K.J. (2006). Depressive symptoms as a predictor of sexual risk among African American adolescents and young adults. Journal of Adolescent Health, 39, e1 e8. Catz, S.L., Kelly, J.A., & Bogart, L.M. (2000). Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychology, 19, 124 133. Ciesla, J.A., & Roberts, J.E. (2001). Meta-analysis of the relationship between HIV infection and risk for depressive disorders. American Journal of Psychiatry, 158, 725 730. Cochran, S.D. (2001). Emerging issues in research on lesbians’ and gay men’s mental health: Does sexual orientation really matter? American Psychologist, 56, 932 947.
Downloaded At: 10:57 24 November 2010
1426
K.R. Sorsdahl et al.
Collins, P.Y., Holman, A.R., Freeman, M., & Patel, V. (2006). What is the relevance of mental health to HIV/ AIDS care and treatment programs in developing countries? A systematic review. AIDS, 20, 1571 1582. Cook, J.A., Grey, D., Burke, J., Cohen, M.H., Gurtman, A.C., Richardson, J.L., . . . Hessol, N.A. (2004). Depressive symptoms and AIDS-related mortality among a multisite cohort of HIV-positive. American Journal of Public Health, 94, 1133 1140. Corrigan, P., Markowitz, R.E., Watson, A., Rowan, D., & Kubiak, M.A. (2003). An attribution model of public discrimination towards persons with mental illness. Journal of Health and Social Behavior, 44, 162 179. Dinos, S., Stevens, S., Serfaty, M., Weich, S., & King, M. (2004). Stigma: The feelings and experiences of 46 people with mental illness. British Journal of Psychiatry, 184, 176 181. Fairfield, K.M., Libman, H., Davis, R.B., & Eisenberg, D.M. (1999). Delays in protease inhibitor use in clinical practice. Journal of General Internal Medicine, 14, 395 401. Farina, A., & Felner, R.D. (1973). Employment interviewer reactions to former mental patients. Journal of Abnormal Psychology, 82, 268 272. Ganasen, K.A., Parker, S., Hugo, C.J., Stein, D.J., Emsley, R.A., & Seedat, S. (2008). Mental health literacy: Focus on developing countries. African Journal of Psychiatry (Johannesburg), 11, 23 28. Gilman, S.E., Cochran, S.D., Mays, V.M., Hughes, M., Ostrow, D., & Kessler, R.C. (2001). Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the National Comorbidity Survey. American Journal of Public Health, 91, 933 939. Green, D., McCormick, I., Walkley, F., & Taylor, A. (1987). Community attitudes to mental illness in New Zealand twenty-two years on. Social Science Medicine, 24, 417 422. Hall, W., Teesson, M., Lynskey, M., & Degenhardt, L. (1999). The 12-month prevalence of substance use and ICD-10 substance use disorders in Australian adults: Findings from the National Survey of Mental Health and Well-Being. Addiction, 94, 1541 1550. Holzemer, W.L., & Uys, L. (2004). Managing AIDS stigma 174. Journal of Social Aspects of HIV/AIDS, 1, 165 174. Hugo, C.J., Boshoff, D.E., Traut, A., Zungu-Dirwayi, N., & Stein, D.J. (2003). Community attitudes toward and knowledge of mental illness in South Africa. Social Psychiatry and Psychiatric Epidemiology, 38, 715 719. Ickovics, J.R., Hamburger, M.E., Vlahov, D., Schoenbaum, E.E., Schuman, P., Boland, R.J., & Moore, J. (2001). Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: Longitudinal analysis from the HIV epidemiology research study. JAMA, 285, 1466 1474. Jacob, K.S., Bhugra, D., Lloyd, K.R., & Mann, A.H. (1998). Common mental disorders, explanatory models
and consultation behaviour among Indian women living in the UK. Journal of the Royal Society of Medicine, 91, 66 71. Jorm, A., Korten, A., Jacomb, P., Christensen, H., Rodgers, B., & Pollitt, P. (1997). ‘‘Mental health literacy’’: A survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment. Medical Journal of Australia, 166, 182 186. Kessler, D., Lloyd, K., Lewis, G., & Gray, D.P. (1999). Cross sectional study of symptom attribution and recognition of depression and anxiety in primary care. BMJ, 318, 436 439. Link, B., Struening, S., Neese-Tood, S., Asmussen, S., & Phelan, J. (2001). Stigma as a barrier to recovery: The consequences of stigma for the self-esteem of people with mental illnesses. Psychiatric Services, 52, 1621 1626. Mant, D., & Fowler, G. (1990). Mass screening: Theory and ethics. BMJ, 300, 916 918. Mbanga, N.I., Neihaus, D.J., Mzamo, N.C., Wessels, C.J., Allen, A., Emsley, R.A., & Stein, D.J. (2002). Attitudes towards and beliefs about schizophrenia in Xhosa families with affected pro-bands. Curationis, 25, 69 74. Perlick, D., Rosenheck, R., Clarkin, J., Sirey, J., Salahi, J., Struening, E., & Link, B. (2001). Adverse effects of perceived stigma on social adaptation of persons diagnosed with bipolar affective disorder. Psychiatric Services, 52, 1627 1632. Robertson, E., & Donnermeyer, J. (1997). Illegal drug use among rural adults: Mental health consequences and treatment utilization. American Journal of Drug and Alcohol Abuse, 23, 467 484. Rosenfield, S. (1997). Labelling mental illness: The effects of received services and perceived stigma on life satisfaction. American Sociological Review, 62, 660 672. Sherbourne, C.D., Hays, R.D., Fleishman, J.A., Vitiello, B., Magruder, K.M., Bing, E.G., . . . Shapiro, M.F. (2000). Impact of psychiatric conditions on healthrelated quality of life in persons with HIV infection. American Journal of Psychiatry, 157, 248 254. Simbayi, L.C., Kalichman, S., Strebel, A., Cloete, A., Henda, N., & Mqeketo, A. (2007). Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Social Science & Medicine, 64, 1823 1831. Sirey, J., Bruce, M., Alexopoulos, G., Perlick, D., Friedman, S., & Meyers, B. (2001). Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatric Services, 52, 1615 1620. Smit, J., Myer, L., Middelkoop, K., Seedat, S., Wood, R., Bekker, L., & D. Stein. (2006). Mental health and sexual risk behaviours in a South African township: A community-based cross-sectional study. Public Health, 120, 534 542.
AIDS Care
Downloaded At: 10:57 24 November 2010
Spire, B., Duran, S., Souville, M., Leport, C., RafďŹ , F., & Moatti, J.P. (2002). Adherence to highly active antiretroviral therapies (HAART) in HIV-infected patients: From a predictive to a dynamic approach. Social Science & Medicine, 54, 1481 1496. Stein, D.J., Seedat, S., Herman, A., Moomal, H., Heeringa, S.G., Kessler, R.C., & Williams, D.R. (2008). Lifetime prevalence of psychiatric disorders in South Africa. The British Journal of Psychiatry, 192, 112 117. Taylor, M., & Dear, M. (1981). Scaling community attitudes toward the mentally ill. Schizophrenia Bulletin, 7, 225 240. Turner, B.J., Laine, C., Cosler, L., & Hauck, W.W. (2003). Relationship of gender, depression, and health care
1427
delivery with antiretroviral adherence in HIV-infected drug users. Journal of General Internal Medicine, 18, 248 257. Watson, A., Corrigan, P., Larson, J., & Sells, M. (2007). Self stigma in people with mental illness. Schizohprenia Bulletin, 33(6), 1312 1318. Wright, A., Jorm, A.F., Harris, M.G., & McGorry, P.D. (2007). What’s in a name? Is accurate recognition and labelling of mental disorders by young people associated with better help-seeking and treatment preferences? Social Psychiatry and Psychiatric Epidemiology, 42, 244 250.