With growing numbers of countries legalizing euthanasia or assisted suicide (EAS), there is a debate as to whether EAS should also be available to people with severe, treatment-resistant mental illness. Excluding mental illness as a legitimate reason to receive EAS has been framed as discriminating against people with mental illness.

We examine whether approval or opposition to psychiatric EAS are related to stigma toward people with mental illness.

We asked a representative sample of the general population in Germany (N = 1515) whether they would approve of EAS for someone with severe, treatment-resistant mental illness. Stigma was assessed with the Value-Based Stigma Inventory (VASI), addressing rejection of people with mental illness in relation to different personal values.

A total of 19% of the German population approved of psychiatric EAS. Higher stigma scores were associated with greater approval of EAS (Spearman rank correlation coefficient, 0.28; P < 0.001). This association held true when controlling for sociodemographic variables. It was strongest for stigma related to perceived threats to one's security, reputation and meritocratic values.

Our results highlight that, although opposing psychiatric EAS is sometimes framed as discriminatory, approval of psychiatric EAS might also carry hidden, stigmatising motives. To avoid any unintended negative consequences for people with severe, treatment-resistant mental illness, any legislation on psychiatric EAS needs to be crafted with particular caution.

Large efforts have been made to erase the stigma of mental illness, but it is unclear whether they have succeeded on a population level. We examine how attitudes toward people with depression or schizophrenia have evolved in Germany since 1990, and whether there are different developments for both disorders.

Using data from the three decades, four wave repeated cross-sectional representative population study in the “old” (western) states in Germany with surveys in 1990 (n = 2,044), 2001 (n = 4,005), 2011 (n = 1,984), and 2020 (n = 2,449), we calculate time-trends for social distance and emotional reactions toward someone with major depression or acute schizophrenia.

Social distance worsened in six out of seven situations for schizophrenia, whereas improving in two out of seven situations for depression. Emotions related to fear and uneasiness increased for schizophrenia, whereas tending to decrease for depression. Pro-social reactions like the desire to help increased for depression, but decreased for schizophrenia. Initially observed differences, favoring depression over schizophrenia, widened over the 30-year study period. For schizophrenia, the biggest negative changes occurred between 1990 and 2001, whereas some improvements with regard to depression occurred more recently.

Contrary to expectations, stigma has become more severe regarding acute schizophrenia in Germany over the last 30 years, whereas only slightly improving for depression. The apparent normalization of mental health problems seems not to directly translate into improving attitudes toward people with severe mental illness. Re-focusing of anti-stigma efforts on people with severe mental illness seems necessary.

Recent network models propose that mutual interaction between symptoms has an important bearing on the onset of schizophrenic disorder. In particular, cross-sectional studies suggest that affective symptoms may influence the emergence of psychotic symptoms. However, longitudinal analysis offers a more compelling test for causation: the European Schizophrenia Cohort (EuroSC) provides data suitable for this purpose. We predicted that the persistence of psychotic symptoms would be driven by the continuing presence of affective disturbance.

EuroSC included 1208 patients randomly sampled from outpatient services in France, Germany and the UK. Initial measures of psychotic and affective symptoms were repeated four times at 6-month intervals, thereby furnishing five time-points. To examine interactions between symptoms both within and between time-slices, we adopted a novel technique for modelling longitudinal data in psychiatry. This was a form of Bayesian network analysis that involved learning dynamic directed acyclic graphs (DAGs).

Our DAG analysis suggests that the main drivers of symptoms in this long-term sample were delusions and paranoid thinking. These led to affective disturbance, not vice versa as we initially predicted. The enduring relationship between symptoms was unaffected by whether patients were receiving first- or second-generation antipsychotic medication.

In this cohort of people with chronic schizophrenia treated with medication, symptoms were essentially stable over long periods. However, affective symptoms appeared driven by the persistence of delusions and persecutory thinking, a finding not previously reported. Although our findings as ever remain hostage to unmeasured confounders, these enduring psychotic symptoms might nevertheless be appropriate candidates for directly targeted psychological interventions.

The EQ-5D is a generic questionnaire generating a health profile and a single index score for health-related quality of life. This study aimed to analyse the discriminative ability and validity of the EQ-5D in patients with schizophrenic, schizotypal or delusional disorders.

One hundred sixty-six patients with schizophrenic, schizotypal or delusional disorders (ICD-10 F2) completed the EQ-5D. Measures of quality of life (WHOQOL-BREF), utility (TTO), subjective (SCL-90R) and objective (PANSS, CGI-S) psychopathology, and functioning (GAF, GARF, SOFAS, HoNOS) provided comparison. Discriminative ability was analysed by assessing frequency distributions of EQ-5D scores. Validity of the EQ-5D self-classifier was analysed by assessing differences in related other scores grouped by response levels of EQ-5D items. Validity of the visual analogue scale (EQ VAS) and the EQ-5D index (UK social tariff) was analysed by assessing their correlation with all other scores.

Seventy-nine percent of respondents reported problems in at least one of the EQ-5D dimensions (anxiety/depression 57%, usual activities 45%, pain/discomfort 44%, self-care 29%, mobility 22%). The mean EQ VAS score/EQ-5D index was 65.7/0.71. The four most frequently reported EQ-5D health states covered 45% of all respondents. For almost all EQ-5D dimensions, different response levels were associated with significantly different scores of measures used for comparison. Correlation of EQ VAS score and EQ-5D index were largest with scores of subjective measures (SCL-90R: −0.50 and −0.73; WHOQOL mental subscore 0.62 and 0.58; always P < 0.001).

The EQ-5D showed a moderate ceiling effect and seems to be reasonably valid in this patient group.

– It is commonly assumed that reforms in the sector of psychiatric care have contributed to reducing the stigma attached to mental illness. In order to examine whether a relation between the psychiatric care set-up and stigmatisation of the patients exists we compared public attitudes towards mental patients in three countries at differing stages of progress in psychiatric reform.

– Population surveys on public attitudes towards mental patients were conducted in Novosibirsk (Russia) and Bratislava (Slovakia). The data were compared with those from a population survey that had recently been carried out in Germany. In all three surveys the same sampling procedure and fully structured interview were used. Public attitude towards mental patients was elicited using a perceived devaluation-discrimination measure.

– Psychiatric patients face considerable rejection in all three locations in question. Overall, the degree of perceived devaluation and discrimination was similar in all countries with a significant, but marginal tendency towards stronger devaluation of mental patients in Germany.

– Our results do not support a strong relationship between psychiatric reform and mental illness stigma.

– The aim of the study is to examine to what extent the public is willing to allocate financial resources to the care of people with mental disorders.

– In 2001, a representative survey was conducted among the adult population of Germany (n = 5025). The respondents were asked to select three out of nine conditions for which available resources should on no account be shortened. For data analysis, multiple unidimensional unfolding was used.

– Compared with medical diseases, the respondents were far less willing to allocate financial resources to the care of people with psychiatric disorders, making a clear distinction between the two types of diseases. While familiarity with mental illness had the effect of decreasing the reluctance to spend money for psychiatric patients, the endorsement of traditional values increased it.

– Our findings point to both the chances and the limitations of efforts aimed at reducing the structural discrimination of people with mental illness.

To quantify and compare the resource consumption and direct costs of medical mental health care of patients suffering from schizophrenia in France, Germany and the United Kingdom.

In the European Cohort Study of Schizophrenia, a naturalistic two-year follow-up study, patients were recruited in France (N = 288), Germany (N = 618), and the United Kingdom (N = 302). Data about the use of services and medication were collected. Unit cost data were obtained and transformed into United States Dollar Purchasing Power Parities (USD-PPP). Mean service use and costs were estimated using between-effects regression models.

In the French/German/UK sample estimated means for a six-month period were respectively 5.7, 7.5 and 6.4 inpatient days, and 11.0, 1.3, and 0.7 day-clinic days. After controlling for age, sex, number of former hospitalizations and psychopathology (CGI score), mean costs were 3700/2815/3352 USD-PPP.

Service use and estimated costs varied considerably between countries. The greatest differences were related to day-clinic use. The use of services was not consistently higher in one country than in the others. Estimated costs did not necessarily reflect the quantity of service use, since unit costs for individual types of service varied considerably between countries.

To examine the evolution of the perception of the stigma attached to mental illness in Germany since 1990 up to the present.

Population surveys were conducted in the old German States (former Federal Republic of Germany) in 1990, 2001, and 2011. The perception of stigma attached to people with mental illness was assessed with the help of Link's perceived discrimination and devaluation scale.

In the 2011 survey, less mental illness stigma was perceived by respondents than in the previous surveys. In the eyes of the German public, the devaluation and rejection of people with mental illness has substantially decreased since 1990.

The perception of a decline of the stigmatization is in contrast to the development of the German public's attitudes towards persons with mental disorders, which remained unchanged or even worsened.

Perceived and personal attitudes towards persons with mental illness have developed differently, and it remains to be seen whether perceptions of less public stigma will ultimately be followed by improved personal attitudes.

The interaction between positive, negative and depressive symptoms experienced by people with schizophrenia is complex. We used longitudinal data to test the hypothesis that depressive symptoms mediate the links between positive and negative symptoms.

We analyzed data from the European Schizophrenia Cohort, randomly sampled from outpatient services in France, Germany and the UK (N = 1208). Initial measures were repeated after 6 and 12 months. Depressive symptoms were identified using the Calgary Depression Scale for Schizophrenia (CDSS), while positive and negative symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS). Latent variable structural equation modelling was used to investigate the mediating role of depression assessed at 6 months in relation to the longitudinal association between positive symptoms at baseline and negative symptoms at 12 months.

We found longitudinal associations between positive symptoms at baseline and negative symptoms at 12 months, as well as between both of these and CDSS levels at 6 months. However depression did not mediate the longitudinal association between PANSS scores; all the effect was direct.

Our findings are incompatible with a mediating function for depression on the pathway from positive to negative symptoms, at least on this timescale. The role of depression in schizophrenic disorders remains a challenge for categorical and hierarchical diagnostic systems alike. Future research should analyze specific domains of both depressive and negative symptoms (e.g. motivational and hedonic impairments). The clinical management of negative symptoms using antidepressant treatments may need to be reconsidered.

Exploring cultural differences may improve understanding about the social processes underlying the stigmatisation of people with mental illness.

To compare public beliefs and attitudes about schizophrenia in Central Europe and North Africa.

Representative national population surveys conducted in Germany (2011) and in Tunisia (2012), using the same interview mode (face to face) and the same fully structured interview.

In Tunisia, respondents showed a stronger tendency to hold the person with schizophrenia responsible for the condition. At the same time they expressed more prosocial reactions and less fear than their German counterparts. In Germany, the desire for social distance was greater for more distant relationships, whereas in Tunisia this was the case for close, family-related relationships.

Stigma differs between Tunisia and Germany more in form than in magnitude. It manifests particularly in those social roles which ‘matter most’ to people within a given culture.

Emotional reactions toward people with disorders are an important component of stigma process. In this study, emotional reactions of the German public toward people with dementia were analyzed.

Analyses are based on a national mail survey conducted in 2012. Sample consists of persons aged 18 to 79 years living in private households in Germany. In all 1,795 persons filled out the questionnaire, reflecting a response rate of 78%. Respondents were asked about their emotional reactions and beliefs about dementia.

A vast majority of the respondents expressed pro-social reactions, i.e. they felt pity, sympathy, and the need to help a person with dementia. Dementia patients rarely evoked anger (10% or less). Between 25% and 50% of the population showed reactions indicating fear. Respondents who had contacts with a person having dementia or had cared for a dementia patient tended to show less negative reactions (fear, anger) and more pro-social reactions. Respondents who showed pronounced fearful reactions were less likely to believe that dementia patients had a high quality of life, were less willing to care for a family member with dementia at home, and were more skeptical about early detection of dementia. Comparison with the results of another study suggests that fearful reactions toward persons with dementia are much more pronounced than in the case of depression, and less pronounced than in the case of schizophrenia.

Fearful reactions toward people with dementia are quite common in the German general public. To reduce fear, educational programs and contact-based approaches should be considered.

Over the past decades, psychiatry, as a science and a clinical discipline, has witnessed profound changes.

To examine whether these changes are reflected in changes in the public's conceptualisation of mental disorders, the acceptance of mental health treatment and attitudes towards people with mental illness.

In 1990 and 2011, population surveys were conducted in Germany on public attitudes about schizophrenia, depression and alcohol dependence.

Although the public has become more inclined to endorse a biological causation of schizophrenia, the opposite trend was observed with the other two disorders. The public's readiness to recommend help-seeking from mental health professionals and using psychotherapy and psychotropic medication has increased considerably. Attitudes towards people with schizophrenia worsened, whereas for depression and alcohol dependence no or inconsistent changes were found.

The growing divide between attitudes towards schizophrenia and other mental disorders should be of particular concern to future anti-stigma campaigns.

Previous community surveys of the drop out from mental health treatment have been carried out only in the USA and Canada.

To explore mental health treatment drop out in the World Health Organization World Mental Health Surveys.

Representative face-to-face household surveys were conducted among adults in 24 countries. People who reported mental health treatment in the 12 months before interview (n = 8482) were asked about drop out, defined as stopping treatment before the provider wanted.

Overall, drop out was 31.7%: 26.3% in high-income countries, 45.1% in upper-middle-income countries, and 37.6% in low/ lower/middle-income countries. Drop out from psychiatrists was 21.3% overall and similar across country income groups (high 20.3%, upper-middle 23.6%, low/lower-middle 23.8%) but the pattern of drop out across other sectors differed by country income group. Drop out was more likely early in treatment, particularly after the second visit.

Drop out needs to be reduced to ensure effective treatment.

Associations between specific parent and offspring mental disorders are likely to have been overestimated in studies that have failed to control for parent comorbidity.

To examine the associations of parent with respondent disorders.

Data come from the World Health Organization (WHO) World Mental Health Surveys (n = 51 507). Respondent disorders were assessed with the Composite International Diagnostic Interview and parent disorders with informant-based Family History Research Diagnostic Criteria interviews.

Although virtually all parent disorders examined (major depressive, generalised anxiety, panic, substance and antisocial behaviour disorders and suicidality) were significantly associated with offspring disorders in multivariate analyses, little specificity was found. Comorbid parent disorders had significant sub-additive associations with offspring disorders. Population-attributable risk proportions for parent disorders were 12.4% across all offspring disorders, generally higher in high- and upper-middle- than low-/lower-middle-income countries, and consistently higher for behaviour (11.0–19.9%) than other (7.1–14.0%) disorders.

Parent psychopathology is a robust non-specific predictor associated with a substantial proportion of offspring disorders.

Biological or genetic models of mental illness are commonly expected to increase tolerance towards people with mental illness, by reducing notions of responsibility and blame.

To investigate whether biogenetic causal attributions of mental illness among the general public are associated with more tolerant attitudes, whether such attributions are related to lower perceptions of guilt and responsibility, to what extent notions of responsibility are associated with rejection of people who are mentally ill, and how prevalent notions of responsibility are among the general public with regard to different mental disorders.

A systematic review was conducted of representative population studies examining attitudes towards people with mental illness and beliefs about such disorders.

We identified 33 studies relevant to this review. Generally, biogenetic causal attributions were not associated with more tolerant attitudes; they were related to stronger rejection in most studies examining schizophrenia. No published study reported on associations of biogenetic causal attributions and perceived responsibility. The stereotype of self-responsibility was unrelated to rejection in most studies. Public images of mental disorder are generally dominated by the stereotypes of unpredictability and dangerousness, whereas responsibility is less relevant.

Biogenetic causal models are an inappropriate means of reducing rejection of people with mental illness.