Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Abstract
Background: There is a growing trend to view depression as a biological illness rather than a
psychosocial condition, even though there is no consensus as to what causes depression.
Furthermore, there are mixed data on the impact of advocating the biological model.
Aims: This study examined public perceptions concerning the etiology of depression as well as
the relationship between such perceptions and treatment preferences, empowerment, and
stigma.
Method: Survey techniques were used to assess how 66 college students view the etiology of
depression. Etiology beliefs, as well as demographic data, were regressed upon measures of
treatment preference, empowerment, and stigma.
Results: Factor analysis produced three distinct models of etiology: biological, psychological,
and environmental. Regression analyses showed that endorsement of the biological model
was associated with increased empowerment, preference for psychotherapy, and decreased
stigma. Endorsing the psychological model was associated with an increased belief that people
can help themselves and increased stigma. Endorsing the environmental model was associated
with a mixture of positive and negative beliefs concerning depression.
Conclusions: Endorsement of each etiological model is associated with both positive and
negative consequences. The current public emphasis on viewing depression as biologically
based should thus be viewed with some caution.
Declaration of interest: None.
Keywords: mental illness (attitudes towards), major depression, etiology, help-seeking
behavior, stigma.
Our world is entering a biological age. how we understand the world and
Through the mapping of the human ourselves. Unsurprisingly, then, there is
genome, genetic engineering, and greater a concerted eort to view mental illness,
understanding of the functions of the and in particular depression, as a biolo-
brain, biology is playing a greater role in gically based disorder. This eort is
Address for Correspondence: Francine Rosselli, Wesleyan University, Department of Psychology, 207 High
Street, Middletown, CT, 06459, USA
ISSN 0963-8237print/ISSN 1360-0567online/2003/060551-13 # Shadowfax Publishing and Taylor & Francis Ltd
DOI: 10.1080/09638230310001627919
552 Benjamin Goldstein & Francine Rosselli
coming from all areas of society and to a public still prefers social explanations to
certain degree has been successful in the causes of depression, there is greater
persuading people to accept a biological acceptance today of medical explanations.
paradigm of depression. Unsurprisingly then, between 1990 and
Anti-stigma organizations, like the 1998 there was a 147.5% increase in the
National Alliance for the Mentally Ill prescription of antidepressants in the
(NAMI), suggest that acceptance of a USA (Skaer et al., 2000). Olfson et al.
biological model of mental illness will (2002) found that patients were 4.8
help reduce the stigma that those who are times more likely to be prescribed an
mentally ill encounter. To this end, antidepressant in 1997 than in 1987.
NAMI uses strictly medical and biologi- Furthermore, during the same time period
cal terminology in their informational there was 10.9% decrease in the percen-
brochure about depression (NAMI, tage of people who received psychother-
2002). Pharmaceutical companies are apy to treat depression. Wyatt & Livson
also pedaling the view of depression as (1994) found that both newer psychiatrists
a biological disease. For example, the and psychologists viewed depression
website for Zoloft explains the biological more medically than older psychiatrists
mechanism by which the antidepressant and psychologists (over 31 years of
works (Zoloft, 2002). The hope is that by experience).
understanding the biology behind depres- However, there has been little public
sion, one would seek a biological solution discussion of the potential impact of how
(a pill) to treat depression. A nal one views depression. How does a given
pressure is coming from insurance com- model, biological, psychological, or en-
panies. In an eort to cut down on costs, vironmental, aect the depressed indivi-
insurance companies prefer that patients dual? Does accepting a biological model
rst consult general practitioners, who induce people to desire pharmaceutical
are primarily prescribing antidepressants treatments? Does a psychological model,
(Hirschfeld, 1998). as NAMI argues, lead to greater stigma?
While there are numerous biological, The present study examined the way
psychological, and environmental the- people view depression and the potential
ories of the causes of depression, lay impact of that perspective on empower-
people have traditionally viewed depres- ment, treatment preferences, and stigma
sion through a psychosocial framework, associated with depression.
virtually ignoring the biological perspec- Szasz (1961) was among the rst to
tive (Angermeryer & Matschinger, 1999). argue against the medicalization of men-
However, the societal forces advocating tal illnesses. More recently, both Keen
the biological model are having an impact. (2000) and Sayce (2000) have also con-
Paykel et al. (1998) compared attitudes tributed to this argument. The two main
towards depression in the UK before and issues in regards to medicalization con-
after the Defeat Depression Campaign, cern how medicalization aects empow-
and found a growing acceptance for erment, specically the belief that people
biological causal explanations and treat- can help themselves and help-seeking
ments for depression. In a comparison of behavior.
past attitudes towards depression in the People with depression, compared to
US, Link et al. (1999) found that while the people without depression, prefer to view
Etiological paradigms of depression 553
concept (Coyne et al., 1998) and lead to some circumstantial evidence that a
treatment discontinuation (Sirey et al., biological model of depression might
2001). serve to reduce stigma by eliminating
One of the key strategies examined for the belief that depression is controllable.
reducing stigma has been education Critics, though, argue that the biologi-
(Mayville & Penn, 1998). However, there cal model does not necessarily reduce
is no consensus as to exactly what stigma (Farina et al., 1978; Read &
information about depression should be Harre, 2001). For example, Farina et al.
emphasized. There are those, such as (1978) found that both the biological
NAMI, who argue that education and model and the psychological model
stigma reduction is best achieved by equally reduce stigma towards the men-
advocating a biological model. The logic tally ill. Additionally, the biological
is that if depression is seen as a psycho- model has been implicated with contri-
logical problem, then it is something that buting to stigma, specically, the viewing
can be controlled by the individual. This of mental patients as more unpredictable
leads to blaming the individual for his or and more violent (Read & Harre, 2001;
her condition or blaming those around Read & Law, 1999). Viewing depression
the individual (typically the mother). If as biologically based, and therefore un-
one is not able to overcome his or her controllable, may thus contribute to
condition, then this indicates a weakness negative beliefs about depression and
of character. A biological conception of fear of those who are depressed. Addi-
depression, then, would hopefully re- tionally, viewing depression in this way
move blame from the individual and may lead to dehumanization. For exam-
place it on uncontrollable factors, such ple, Mehta & Farina (1997) found a
as ones biochemistry. tendency to be indierent towards the
There is some evidence to back up this feelings of mental patients when a
claim, however none of it is direct. biological perspective was employed.
Firstly, it has been shown that more However, there are problems with this
stigma is attached to people with dis- argument as well. Read & Harre (2001)
abilities when those disabilities are seen and Farina et al. (1978) only demon-
as controllable (Jones et al., 1984). strated the biological model to be in-
Furthermore, depression is seen as more eective in reducing stigma; they did not
controllable and stable than other physi- nd the psychological model to be any
cal illnesses (Corrigan et al., 2000), and more eective. Furthermore, all the
not surprisingly depression generates studies cited examined mental illness as
more negative emotions and stereotypes a whole rather than depression. The
than physical illnesses (Esses & Beaufoy, common prototype of mental illness is
1994). Finally, those who view depres- not necessarily a depressed individual, so
sion as biologically based are less likely while these studies implicate criterion
to blame depressed individuals for task that may lead to the stigmatization of
failures (Mehta & Farina, 1997). Taken depression, they are by no means con-
as a whole, research has shown that clusive.
controllable illnesses provoke greater In sum, we are in a situation where a
stigmatization and that depression is seen biological perspective of depression is
as a controllable illness. There is thus being thrust upon the public, but there is
Etiological paradigms of depression 555
no reason to believe that this provides a look on the world), environmental (e.g.
complete portrayal of depression or will general stress), and personal explanations
necessarily yield positive outcomes. The of depression (e.g. lack of will power). To
present study employed a survey to assess treatment preferences, participants
examine public beliefs concerning the were asked to rate the perceived eec-
causes of depression and the relationship tiveness of antidepressants and psy-
between particular etiological perspec- chotherapy (7 3 = denitely ineective;
tives and empowerment, treatment pre- 3 = denitely eective).
ferences, and stigma. Empowerment was assessed in terms of
beliefs concerning whether depressed
Method people are to blame for their condition,
the degree to which depression could be
Participants treated by oneself, and how likely one is
Participants included 44 female and 22 to seek treatment. Participants were rst
male Wesleyan University students ran- asked to rate their agreement with the
ging in age from 18 to 22. Twenty-nine statement people with depression have
participants identied themselves as hav- themselves to blame for their depression,
ing had depression, and 11 participants ( 7 3 = strongly disagree; 3 = strongly
identied themselves as being currently agree). Participants were also asked
depressed. Thirty-one students from an how eective it is to deal with depression
introductory psychology class completed alone ( 7 3 = denitely ineective;
the survey in order to fulll 1 hour of 3 = denitely eective). Finally, to assess
course credit. Another 35 university how likely one was to seek help, partici-
students responded to yers asking for pants were asked to rate how likely they
volunteers for a study on attitudes would be to seek help from seven various
towards depression, and received no individuals including a psychiatrist, a
credit for their participation. family doctor, a psychologist, signicant
other, friend, parent, and self ( 7 3 = de-
Materials nitely would not seek help from;
The survey was constructed to examine 3 = denitely would seek help from).
four aspects of attitudes towards depres- Since these seven individuals provide a
sion: perceived etiology, degree of em- large range of help-seeking options,
powerment, preferred treatment, and responses to these items were averaged
stigma towards depressed people. Re- together to generate an overall measure
sponses to all of these questions were of help-seeking behavior.
assessed using seven-point scales ranging To assess stigma associated with de-
from of 7 3 to 3. pression, participants rst rated their
To assess perceived etiology, partici- agreement with the statement people
pants were asked to rate whether a given with depression take more from a rela-
factor was a cause of depression tionship than they give back,
(7 3 = denitely not a cause; 3 = de- ( 7 3 = strongly disagree; 3 = strongly
nitely a cause). Choices were given to agree). Participants were also asked to
reect a large range of possible biological rate the likelihood that a depressed
(e.g. genetic or inherited predisposition), person, compared to a non-depressed
psychological (e.g. poor cognitive out- person, would be violent and have poor
556 Benjamin Goldstein & Francine Rosselli
Factors
Survey item Biology Psychology Environment
Chemical/hormone imbalance 0.838* 7 0.216 0.021
Genetic predisposition 0.775* 7 0.335 7 0.035
Biological changes 0.635* 0.450 0.211
Lack of will power 7 0.140 0.830* 0.085
Melancholic personality 0.032 0.785* 0.343
Poor cognitive outlook 7 0.177 0.781* 0.298
Helplessness/hopelessness 7 0.080 0.648* 7 0.071
Lack of social support 7 0.197 0.553* 7 0.025
General stress 0.167 0.105 0.840*
Negative life event 0.098 0.000 0.728*
Expecting too much 7 0.370 0.242 0.603*
* Designates highest loading.
violent, poor friendships, the positive ment with the beliefs that depressed
belief index, and the social distance people have poor friendships and take
index). more than they give in relationships.
As can be seen from the standardized Finally, greater agreement with the
regression coecients presented in Table environmental model of depression was
2, acceptance of the biology factor was associated with reduced desired social
associated with greater empowerment in distance and less agreement that de-
the form of greater help-seeking behavior pressed people are to blame for their
and less of a belief that depressed people condition. It was also associated with an
are to blame for their condition. Also, increased belief that depressed people are
endorsing this model was associated with more violent than non-depressed people.
increased acceptance of eectiveness of
psychotherapy as a treatment for depres- Discussion
sion. However, it did not predict in-
creased acceptance of the eectiveness of The purpose of this study was to assess
antidepressants. Finally, endorsement of lay beliefs concerning the etiology of
the biological factor was associated with depression and to examine the relation-
positive beliefs about depressed people. ship between such beliefs and empower-
Endorsing the psychology model pre- ment, treatment preferences, and
dicted greater acceptance in the eective- stigmatization of depressed individuals.
ness of dealing with depression by The results suggest that participants
oneself. However, endorsing this model recognized three dierent etiologies of
also predicted an acceptance of the belief depression: biological factors, psychol-
that depressed people are to blame for ogy/personality factors, and environmen-
their condition. It also led to increased tal factors. The biological model included
stigma in the form of greater desired beliefs that depression stems from che-
social distance as well as stronger agree- mical or hormone imbalances, biological
558 Benjamin Goldstein & Francine Rosselli
changes in the brain or nervous system, much of ones self. Aside from the lack
and a genetic or inherited predisposition. of the social support item not loading on
These were the expected characteristics of this factor, this factor was expected and
the biological model and are consistent incorporates most of the environmental
with publicized biologically-based repre- explanations of depression.
sentations of depression (e.g. NAMI, Endorsement of the biological model
2002). The psychology/personality fac- generally led to empowerment. Consis-
tors included lack of will power, melan- tent with Kuyken et al. (1992) and
cholic personality, poor cognitive Gammel & Stoppard (1999), participants
outlook, learned helplessness/hopeless- who expressed greater acceptance of the
ness, and lack of social support. This biological model were less likely to blame
factor thus reects both current psycho- depressed individuals for their condition.
logical theories (e.g. cognitive outlook, However, inconsistent with Fisher &
learned helplessness/hopelessness) and Farina (1979), who found that the
personality based explanations (e.g. lack psychosocial model led to greater help-
of will power, melancholic personality). seeking behavior than the biological
The only surprising element of this factor model, endorsement of the biological
is the lack of social support, which model in the present study predicted
might be expected to be part of the greater help-seeking behavior. It is pos-
environmental factor. However, this item sible that the rise of more eective
did have a lower factor loading than the antidepressants has led people who en-
rest of the items. Finally, the environ- dorse the biological model to believe that
ment factor included general stress, one can treat depression, and therefore
negative life events, and expecting too believe treatment should be sought.
Etiological paradigms of depression 559
sion. This movement clearly benets are legitimate, as the biological model
particular interest groups. For example, does reduce the belief that people can
it consolidates the power of psychiatrists help themselves.
(Szasz, 1987) and increases prots for In conclusion, we have shown that the
pharmaceutical and insurance compa- etiological model one endorses is signi-
nies. In addition, some advocates of this cantly related to issues of empowerment,
view argue that conceptualizing depres- treatment preference, and stigma. In
sion as a biologically based illness reduces addition, this study demonstrates that
stigma. This study was an attempt to examining the models people use to
document lay beliefs concerning the conceptualize depression is a valuable area
causes of depression and to examine the of research. Undoubtedly, more work is
potential implications of those beliefs. needed in this area, as our conceptualiza-
We did nd that our college student tion of an idea, like depression, can greatly
sample recognized distinct biological, psy- impact our understanding of that idea and
chological, and environmental causes of inuence further beliefs.
depression. Unfortunately, none of the
models was clearly superior to the others.
While the biological model did appear to be
related to increased help-seeking behavior References
and reduction of some stigma beliefs, it did
Angermeyer, M.C. & Matschinger, H. (1996).
not help in one of the most important areas
Public attitudes towards psychiatric treatment.
of stigma reduction, desired social dis- Acta Psychiatrica Scandinavica, 94, 326 336.
tance. The psychological model, while it Angermeyer, M.C. & Matschinger, H. (1999). Lay
was associated with increased stigma as beliefs about mental disorders: A comparison
dened by negative beliefs and increased between the western and eastern parts of
Germany. Social Psychiatry & Psychiatric
social distance, did have the benet of Epidemiology, 34, 275 281.
improving the belief that one can help Angermeyer, M.C., Matschinger, H. & Riedel-
oneself. The environmental model was Heller, S.G. (1999). Whom to ask for help in
associated with reduced blame and social case of mental disorder? Preferences of the lay
public. Social Psychiatry & Psychiatric Epide-
distance, but was also associated with miology, 34, 202 210.
increased negative beliefs. Arkar, H. & Eker, D. (1994). Eect of psychiatric
These ndings could have public policy labels on attitudes towards mental illness in a
implications. If one wants to increase Turkish sample. The International Journal of
Social Psychiatry, 40, 205 213.
help-seeking behavior and reduce stigma, Corrigan, P.W., River, P., Lundin, R.K., Wa-
it appears that advocating the biological sowski, K.U., Campion, J., Mathisen, J.,
model would be an eective strategy. Goldstein, H., Bergman, M., Gagnon, C. &
Furthermore, the biological model does Kubiak, M.A. (2000). Stigmatizing attribu-
tions about mental illness. Journal of Commu-
not appear to direct people toward
nity Psychology, 28, 91 102.
antidepressants as some fear. This seems Coyne, J.C. (1987). Depression, biology, marriage
to indicate that the biological movement and marital therapy. Journal of Marital &
is not all together a bad thing, as there Family Therapy, 13, 393 407.
Coyne, J.C., Gallo, S.M., Klinkman, M.S. &
are some advantages associated with the
Calarco, M.M. (1998). Eects of recent and
biological perspective. However, there is past major depression and distress on self-
a cost associated with it. The fears of concept and coping. Journal of Abnormal
Szasz (1961), Keen (2000), and others, Psychology, 107, 86 96.
562 Benjamin Goldstein & Francine Rosselli
Esses, V.M. & Beaufoy, S.L. (1994). Determinants Kurihara, T., Kato, M., Sakamoto, S., Reverger,
of attitudes toward people with disabilities. R. & Kitamura, T. (2000). Public attitudes
Journal of Social Behavior and Personality, 9, towards the mentally ill: A cross-cultural study
43 64. between Bali and Tokyo. Psychiatry and
Farina, A., Fisher, J.D., Getter, H. & Fischer, Clinical Neurosciences, 54, 547 552.
E.H. (1978). Some consequences of changing Kuyken, W., Brewin, C.R., Power, M.J. &
peoples views regarding the nature of mental Furnham, A. (1992). Causal beliefs about
illness. Journal of Abnormal Psychology, 87, depression in depressed patients, clinical psy-
272 279. chologists, and lay persons. British Journal of
Fazio, R.H. & Roskos-Ewoldsen, D.R. (1994). Medical Psychology, 65, 257 268.
Acting as we feel: When and how attitudes Link, B.G., Phelan, J.C., Bresnahan, M., Stueve,
guide behavior. In S. Shavitt & T.C. Brock A. & Pescosolido, B.A. (1999). Public concep-
(eds), Persuasion: Psychological insights and tions of mental illness: Labels, causes, danger-
perspectives (pp. 71 93). Boston: Allyn and ousness, and social distance. American Journal
Bacon. of Public Health, 89, 1328 1333.
Fisher, J.D. & Farina, A. (1979). Consequences of Mayville, E. & Penn, D.L. (1998). Changing
beliefs about the nature of mental disorders. societal attitudes toward persons with severe
Journal of Abnormal Psychology, 88, 320 327. mental illness. Cognitive and Behavioral Prac-
Furnham, A. & Malik, R. (1994). Cross-cultural tice, 5, 241 253.
beliefs about depression.. The International Mehta, S. & Farina, A. (1997). Is being sick
Journal of Social Psychiatry, 40, 106 123. really better? Eect of the disease view of
Gammell, D.J. & Stoppard, J.M. (1999). Womens mental disorder on stigma. Journal of Social
experience of treatment of depression: Medi- and Clinical Psychology, 16, 405 419.
calization or empowerment? Canadian Psy- Mulatu, M.S. (1999). Perceptions of mental and
chology, 40, 112 128. physical illnesses in north-western Ethiopia:
Hirschfeld, R.M. (1998). American health care Causes, treatments, and attitudes. Journal of
systems and depression: The past, present and Health Psychology, 4, 531 549.
the future. The Journal of Clinical Psychiatry, National Alliance for the Mentally Ill. (2002).
59[suppl. 20]: 5 10. Understanding major depression. What you
Jones, E.E., Farina, A., Hastorf, A.H., Markus, need to know about this medical illness [Bro-
H., Miller, D.T. & Scott, R.A. (1984). Social chure]. Arlington, VA.
stigma: The psychology of marked relation- Olfson, M., Marcus, S.C., Druss, B., Elinson, L.,
ships. New York: W.H. Freeman and Com- Tanielian, T. & Pincus, H.A. (2002). National
pany. trends in the outpatient treatment of depres-
Jorm, A.F., Korten, A.E., Jacomb, P.A., Chris- sion. Journal of the American Medical Associa-
tensen, H. & Henderson, S. (1999). Attitudes tion, 287, 203 209.
towards people with mental illness: A survey Paykel, E.S., Hart, D. & Priest, R.G. (1998).
of the Australian public and health profes- Changes in public attitudes to depression
sionals. Australian and New Zealand Journal of during the Defeat Depression Campaign.
Psychiatry, 33, 77 83. British Journal of Psychiatry, 173, 519 522.
Jorm, A.F., Korten, A.E., Rodgers, B., Pollitt, P., Read, J. & Harre, N. (2001). The role of biological
Jacomb, P.A., Christensen, H. & Jiao, Z. and genetic causal beliefs in the stigmatisation
(1997). Belief systems of the general public of mental patients. Journal of Mental Health,
concerning the appropriate treatments for 10, 223 235.
mental disorders. Social Psychiatry and Psy- Read, J. & Law, A. (1999). The relationship of
chiatric Epidemiology, 32, 468 473. causal beliefs and contact with users of mental
Keen, E. (2000). Chemicals for the mind: Psycho- health services to attitudes to the mentally ill.
pharmacology and human consciousness. West- International Journal of Social Psychiatry, 45,
port, CT: Praeger. 216 229.
Kramer, P.D. (1993). Listening to Prozac. New
York: Viking.
Etiological paradigms of depression 563
Sayce, L. (2000). From psychiatric patient to Szasz, T.S. (1961). The myth of mental illness:
citizen. Overcoming discrimination and social Foundations of a theory of personal conduct.
exclusion. New York: St. Martins Press, Inc. New York: Paul B. Hoeber, Inc.
Sirey, J.A., Bruce, M.L., Alexopoulos, G.S., Szasz, T.S. (1987). Insanity: The idea and its
Perlick, D.A., Raue, P., Friedman, S.J. & consequences. New York: John Wiley & Sons.
Meyers, B.S. (2001). Perceived stigma as a Wyatt, R.C. & Livson, N. (1994). The not so great
predictor of treatment discontinuation in divide? Psychologists and psychiatrists take
young and older outpatients with depression. stands on the medical and psychosocial models
American Journal of Psychiatry, 158, 479 481. of mental illness. Professional Psychology:
Skaer, T.L., Sclar, D.A., Robison, L.M. & Galin, Research and Practice, 25, 120 131.
R.S. (2000). Trend in the use of antidepressant Zoloftwebsite(n.d.)RetrievedMarch17,2002,from
pharmacotherapy and diagnosis of depression http://www.zoloft.com/index.asp?pageid = 2.
in the US. CNS Drugs, 14, 473 481.