Differences in beliefs and attitudes toward Depression and Schizophrenia in Russia and the United States

Abstract

Background:

Cross-cultural studies find that culture shapes people’s understanding of mental illnesses, particularly Depression and Schizophrenia.

Aims:

To compare individuals’ beliefs and attitudes toward Depression and Schizophrenia in Russia and the United States.

Method:

Participants (N=607) were presented with vignettes of two diagnostically unlabeled psychiatric case histories and then answered questions regarding mental health literacy (MHL) and attitudes toward the person and the illness.

Results:

Our findings indicate that Depression was most often attributed to psychosocial stress while Schizophrenia was thought to be caused by biological factors. People from both countries considered those suffering from Schizophrenia to be unpredictable and dangerous. US participants were more likely to endorse lay and professional help for both disorders than their Russian counterparts. Russian participants reported being less likely to turn to someone they trust and more likely to deal with problems on their own. Russian participants were also more likely to view those with Depression as ‘weak-willed’ and leading an ‘immoral lifestyle’.

Conclusion:

Our findings further inform cultural understandings of these mental illnesses in an often neglected national group. Patterns suggest that both groups may benefit from exposure to corrective information about Depression and Schizophrenia.

Keywords

Depression Schizophrenia mental health beliefs cultural differences mental health treatment

Mental illness affects roughly 25% of adults at least once in their lives. Depression, which manifests as a combination of low mood and psychosomatic symptoms such as sleep problems and weight changes, is the leading cause of disability worldwide, with over 300 million people affected (World Health Organization, 2017). Schizophrenia, although rarer than Depression, is a severe mental disorder marked by hallucinations, delusions, disorganized speech and behavior, affective flattening and social isolation, affecting more than 21 million people worldwide (Barbato, WHO Nations for Mental Health Initiative, 1997). In the Russian Federation, mental illness is a major public health challenge; about 20% of people registered as disabled suffer from a mental illness (Jenkins et al., 2007; Marquez, 2005).

Despite the availability of effective treatments, many people do not seek help for their mental health issues (Boenisch et al., 2012). Beliefs about mental illness and its treatment can act as barriers to seeking treatment (Dear & Taylor, 1982; Hugo, Boshoff, Traut, Zungu-Dirwayi, & Stein, 2003). This is important as knowledge and attitudes toward mental illness affect treatment-seeking and treatment adherence (Angermeyer & Matschinger, 1994; Jorm, Christensen, & Griffiths, 2005; Jorm et al., 1997a; Lauber, Nordt, & Rössler, 2005). Previous research finds that the inability to identify symptoms is one of the most important barriers to early recognition and help-seeking (Dear & Taylor, 1982; Gulliver, Griffiths, & Christensen, 2010; Martin, Pescosolido, & Tuch, 2000). For example, the belief that Depression is under one’s control is associated with less help-seeking behavior (Halter, 2004).

Stigmatization of mental illness also reduces treatment seeking (Martin et al., 2000; Perry, Pescosolido, Martin, McLeod, & Jensen, 2007). Stigmatizing attitudes include perceiving those with mental illness as violent, unpredictable and weak (Angermeyer, Matschinger, & Schomerus, 2013; Henderson & Thornicroft, 2009; Jorm et al., 1997b; Wang & Lai, 2008). This is particularly true of people suffering from Schizophrenia, who are wrongly considered dangerous and unpredictable (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000; Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999). Although a meta-analysis conducted in Canada found that the likelihood of aggressive behavior among all mentally ill persons is slightly greater than in the general population, laypeople overestimate and overgeneralize this risk (Douglas, Guy, & Hart, 2009).

Though both Depression and Schizophrenia have been the focus of anti-stigma interventions (Angermeyer & Matschinger, 2003), studies find that nearly 80% of people with Depression have experienced discrimination (Lasalvia et al., 2012). Some of the stigmatization may be due to beliefs about what causes mental illness. Laypeople typically cite different causal explanations for Depression and Schizophrenia, with Schizophrenia seen as biological in origin and Depression as caused by psychosocial factors (Angermeyer, Millier, Rémuzat, Refa, & Toumi, 2013; Jorm et al., 1997b; Link et al., 1999; Schomerus, Matschinger, & Angermeyer, 2006). Cultural beliefs may play a major role in shaping perceptions, attitudes and behavior toward people with mental illness (e.g., Dietrich et al., 2004; Jorm & Oh, 2009; Turvey, Jogerst, Kim, & Frolova, 2012). Cultural norms shape judgments of what is normal and what is deviant (Angermeyer, Matschinger, & Corrigan, 2004; Stefanovics et al., 2016). For example, Thakker and Ward (1998) report that many cultural groups do not even have a word for ‘depressed’. Cross-Atlantic findings suggest that published research abstracts focused more on biological explanatory factors for Schizophrenia in a US psychiatry flagship journal, while psychosocial factors were more likely to be acknowledged in its British counterpart (Jarvis, Bhat, Jurcik, Spigonardo, & Whitley, 2015). Hence, country differences in causal perceptions may be apparent not only at public but also at professional levels.

Of particular interest to us is how beliefs and attitudes about mental illness in the United States differ from those in Russia – two countries with different histories and cultural norms (Jurcik, Chentsova-Dutton, Solopieieva-Jurcikova, & Ryder, 2013). In their review, Jurcik and colleagues (2013) report that historical factors in Russia such as communism and its aftermath may have led to mistrust of authority figures, which can generalize to the client–therapist relationship. Perhaps, as a result, of the misuse of psychiatry as a tool of political oppression during the Soviet era, Russians may be more likely to trust close friends and loved ones with their problems than mental health professionals. Americans, on the other hand, more readily trust authority figures, including therapists and psychiatrists (Jurcik et al., 2013; Leipzig, 2006). This discrepancy may explain why Russians underutilize mental health services compared with Western countries (Hundley & Lambie, 2007; Jurcik et al., 2013; Leipzig, 2006).

Dietrich and colleagues (2004) investigated the Russian population’s beliefs about mental disorders and found that Russians tended to view depressed individuals as lacking ‘will power’ or embracing an ‘immoral life style’. Moreover, they found that, compared with German participants, Russians were more likely to attribute causes of mental illness to families, citing difficulties with socialization (Dietrich et al., 2004). Concordantly, Turvey and colleagues (2012) found that, compared with US participants, Russian participants were more likely to attribute the cause of Depression to ‘personal weakness’. Nevertheless, compared with Westerners, Russians as a group may tend to report, express and perhaps even be motivated by more negative emotions (e.g. sadness) than positive ones (e.g. joy), according to various study findings, possibly reflecting differences in cultural norms, coping styles and sociopolitical history (see Jurcik et al., 2013 for review). Social norms influence how Depression and other mental illnesses are perceived within a culture, and lingering negative affect, a core symptom of Depression, may be more normalized and less pathologized in Russia.

Grossmann and Varnum (2011) reported that Russians endorse more interdependent self-views than Americans. However, Russian collectivism is different from that of East Asian collectivism. Russians are more individualistic than East Asians, with whom Americans have traditionally been compared. Asian collectivism tends to value maintaining harmony while Russians are more likely to provide direct ‘in your face’ social support (Chentsova-Dutton, 2012). So, sitting, as it does, between East Asian collectivist cultures and Western individualistic ones, Russian culture provides a unique cultural comparison with the United States (Jurcik et al., 2013).

Henrich, Heine, and Norenzayan (2010) suggest that members from Western, educated, industrialized, rich and democratic societies – the population that most behavioral science research targets – are actually the least representative of humans as a whole. While numerous clinical comparisons have been made with East Asian groups, more clinical research is needed in other non-Western populations, including those in Eurasia (Jurcik et al., 2013). From our review of the literature, we identified only one study comparing American and Russian beliefs about and attitudes toward psychiatric illness (Turvey et al., 2012). Moreover, relatively little research in the field of cultural-clinical psychology has been conducted in Russia (Jurcik et al., 2013). Thus, little is known about Russian attitudes toward mental illness, despite Russia being the ninth most populous nation in the World (Shulman & Adams, 2002; United Nations, 2017). The GAMAIN-Europe study collected data on self-stigma and perceived discrimination across 13 European countries, but excluded Russia due to insufficient data (Brohan, Gauci, Sartorius, Thornicroft, & GAMIAN–Europe Study Group, 2011). Several former communist countries, including the Czech Republic, Ukraine and Bulgaria were also excluded due to lack of data. This is problematic since the lack of research on knowledge about and opinions and attitudes toward Depression and severe mental illness has implications for culturally informed care. Clearly, more research on Russian beliefs about and attitudes toward mental health is needed.

Accordingly, we predict that (H1a) participants will endorse psychosocial factors as the cause of Depression more often than for Schizophrenia; (H1b) participants will cite biological causes of Schizophrenia more often than Depression; (H2 ) participants will describe people with Schizophrenia as unpredictable and dangerous, more than people with Depression; (H3a) participants in the United States will endorse biological causes of Depression and Schizophrenia more strongly than participants in Russia; (H3b ) compared with the United States, participants in Russia will credit psychosocial causes for both Depression and Schizophrenia; (H4a) participants in Russia will endorse more lay help-seeking beliefs than participants in the United States; (H4b ) participants in the United States will endorse more professional help-seeking than participants in Russia; (H5) participants in Russia will view Depression as a personal weakness, citing ‘weak will’ and ‘immoral lifestyle’ more than participants in the United States.

Method

Participants

We recruited participants from Russia and the United States (see Table 1). Our sample consisted of 188 Russian participants, of which 106 were female (56.4%), and 419 US participants, of which 256 were female (61.1%). Participants’ ages ranged from 18 to 84 years. The Russian sample was slightly younger (M = 31.00, standard deviation (SD) = 11.55) than the US sample (M = 35.98, SD = 13.74), t(574) = 4.26, p < .001. About half of the participants in both samples had completed a bachelor’s degree (44.2% in the United States vs 51.3% in Russia). However, the US sample had more participants who had only completed some college (19.3% in the United States vs 5.3% in Russia), χ² (7, N = 607) = 41.99, p < .001. We thus controlled for age and education in our subsequent analyses. Table 1 summarizes demographic information.

Table 1.

Demographic information (N = 607).

	Total	Total (%)	Russia	Russia (%)	United States	United States (%)
Total
Total participants	607	100	188	31	419	69
Gender
Male	245	40	82	44	163	39
Female	362	60	106	56	256	61
Age (years)
18–24	105	17	76	41	26	7
25–34	287	47	54	29	233	56
35–44	73	12	22	12	52	12
45–54	45	8	18	10	27	7
55–64	42	7	12	6	30	7
65+	23	4	1	1	22	5
Educational level
Less than high school	2	0	1	1	1	0
General Educational Development (GED)	7	1	7	4	0	0
High school diploma	18	3	9	5	9	2
Some college	91	15	10	5	81	19
Bachelor’s degree	281	46	96	51	185	44
Master’s degree	166	27	57	30	109	26
Doctorate	41	7	7	4	34	8

Measures

Survey on public beliefs and attitudes toward psychiatric illnesses

We conducted a vignette-based study utilizing a measure that was originally developed in Germany and later used in France (Angermeyer, Matschinger, & Schomerus, 2013; Angermeyer, Millier, et al., 2013). It fulfilled the criteria of the Diagnostic and Statistical Manual of Mental Disorders, (3rd ed., rev.; DSM-III-R; American Psychiatric Association, 1987) for definitions of Major Depressive Disorder and Schizophrenia. The survey was professionally translated into Russian and English and verified by native and multilingual speakers of all three languages to ensure comprehensibility and comparability.

Procedure

The study was approved by the institutional review board. We collected data through snowball sampling (Goodman, 1961) via two popular social media networks: Facebook and VKontakte, popular in the United States and Russia, respectively. An advertisement was placed on these social media platforms in English (Facebook) and Russian (VKontakete). Participants were encouraged to forward the advertisement to their acquaintances, who in turn were encouraged to do the same. Snowball sampling is an efficient and inexpensive way to gather data although as a non-random sampling technique it is prone to bias (Goodman, 1961).

Participants were presented with vignettes of two diagnostically unlabeled psychiatric case histories, depicting one case of Depression and one case of Schizophrenia in a male (Angermeyer, Matschinger, & Schomerus, 2013; Angermeyer, Millier, et al., 2013). The participants then answered questions regarding mental health literacy (MHL) and attitudes toward the person and the illness, including causal attributions and help-seeking recommendations. We also measured emotional reactions to the person described in the vignette (Angermeyer, Matschinger, & Schomerus, 2013; Angermeyer, Millier, et al., 2013).

Causal attributions were measured on a 5-point Likert-type scale ranging from ‘Not likely’ to ‘Very likely’. Participants were asked how likely they thought the items caused the problem described in the vignette. Three items concerned psychosocial stress: ‘problems with partner and/or family’, ‘stressful life event’ and ‘work-related stress’. Three items concerned biological explanations: ‘brain disease’, ‘hereditary defect’ and ‘chemical imbalance in the brain’ (Angermeyer, Matschinger, & Schomerus, 2013; Angermeyer, Millier, et al., 2013). Other items included ‘weak will’ and ‘immoral lifestyle’.

Next, participants were asked how the person could best be helped using a 5-point Likert scale ranging from ‘Strongly discourage’ to ‘Strongly encourage’. Items included ‘join a self-help group’, ‘confide in a religious leader’, ‘turn to someone he trusts’, ‘tell him to do something about this problem by himself’ and ‘search the Internet’. Professional help-seeking items included ‘go to a family doctor or general practitioner’, ‘go to a psychotherapist’ and ‘consult a psychiatrist’. Participants then answered questions about their attitudes toward the disorders and the people who suffer from them. Participants rated how much certain descriptors correspond to the person in the vignette, including ‘dangerous’ and ‘unpredictable’ on a 5-point Likert-scale ranging from ‘Strongly disagree’ to ‘Strongly agree’.

Results

Data integrity and analyses

Data from the online questionnaire were exported from the survey software and analyzed using SPSS, v. 22. Univariate outliers were winsorized to 3.3 SDs from the mean with rank order preserved. Since items were analyzed separately rather than part of a scale, Bonferroni corrections were used to control for Type I error. Student t-tests were conducted for the first set of hypotheses for the entire sample, collapsed by country. We checked for differences in background variables between the two sub-samples (i.e. age, gender, education, marital and employment status), but only age and education differed significantly between our American and Russian participants (see ‘Participants’ section). Hence, in order to preserve statistical power for subsequent mixed-design analysis of covariance (ANCOVA), only age and education were used as control variables.

Psychosocial and biological factors

Paired samples t-tests showed a significant difference between causal attributions for Depression and Schizophrenia (see Table 2). There were several significant differences between the two disorders. Table 2 summarizes the findings related to causal attributions.

Table 2.

Means for beliefs about biological and psychosocial factors as causes of Depression and Schizophrenia.

	Depression		Schizophrenia		t	df	Significance (two-tailed)
	M	SD	M	SD
Psychosocial factors
Stressful life event	4.24	0.87	3.42	1.26	14.89	597	<.001
Work-related stress	3.90	0.99	2.83	1.31	18.26	600	<.001
Problems with partner/family	3.77	1.00	2.52	1.18	22.58	595	<.001
Biological factors
Chemical imbalance	3.67	1.26	4.30	1.03	13.57	599	<.001
Brain disease	2.60	1.28	3.90	1.19	23.34	599	<.001
Hereditary defect	2.55	1.20	3.75	1.18	22.65	593	<.001

SD: standard deviation; df: degrees of freedom.

Participants endorsed ‘Stressful Life Event’, ‘Work-Related Stress’ and ‘Problems with Partner/Family’, as causes of Depression significantly more often than for Schizophrenia. By contrast, participants endorsed ‘Chemical Imbalance’, ‘Brain Disease’ and ‘Hereditary Defect’ as causes of Schizophrenia significantly more often than for Depression.

Dangerousness and predictability

Analyses revealed a significant difference between participants’ perceptions of those with Depression versus Schizophrenia on ratings of dangerousness and unpredictability. Participants tended to rate the Schizophrenia vignette as more unpredictable (M=4.29; SD=0.91) than the one with Depression (M=2.73; SD=1.10), F(1, 563) = 48.55, p < .001, $η_{p}^{2} = . 079$ . Similarly, they also associated dangerousness more with Schizophrenia (M=3.33; SD=1.15) than with Depression (M=1.88; SD=1.00), F(1, 563) = 31.30, p < .001, $η_{p}^{2} = . 053$ .

Biological versus psychosocial causation

ANCOVAs revealed that Russian participants endorsed psychosocial causes for both disorders more often than their American counterparts (see Table 3).

Table 3.

ANCOVA for beliefs about psychosocial factors as causes of depression and schizophrenia in the United States and Russia.

	F	p	$η_{p}^{2}$	Depression				Schizophrenia
				M_US	SD_US	M_Russia	SD_Russia	M_US	SD_US	MRussia	SD_Russia
Current psychosocial stress
Stressful life event				4.14	.87	4.48	0.83	3.23	1.24	3.81	1.22
Disorder	1.66	.196	.003
Country	29.21	.001	.049
Disorder × Country	2.75	.098	.005
Work-related stress				3.83	0.96	4.04	1.05	2.68	1.28	3.10	1.36
Disorder	1.54	.215	.003
Country	14.08	<.001	.024
Disorder × Country	1.68	.196	.003
Problems with partner/family				3.68	0.95	3.96	1.09	2.34	1.11	2.87	1.27
Disorder	8.29	.004	.015
Country	23.5	<.001	.04
Disorder × Country	3.98	.046	.007

ANCOVA: analysis of covariance; SD: standard deviation.

Age and education were used as covariates.

American participants tended to rate biological causes higher for both disorders. The items were each analyzed separately (see Table 4).

Table 4.

ANCOVA for beliefs about biological factors as causes of Depression and Schizophrenia in the United States and Russia.

	F	p	$η_{p}^{2}$	Depression				Schizophrenia
				M_US	SD_US	M_Russia	SD_Russia	M_US	SD_US	M_Russia	SD_Russia
Biological factors
Brain disease				2.71	1.27	2.27	1.23	3.91	1.19	3.88	1.19
Disorder	16.57	<.001	.029
Country	7.1	.008	.012
Disorder × Country	11.43	.001	.02
Hereditary defect				2.75	1.18	2.09	1.15	3.75	1.19	3.78	1.18
Disorder	26.48	<.001	.045
Country	13.73	<.001	.024
Disorder × Country	35.89	< .001	.06
Chemical imbalance				4.03	.99	2.84	1.42	4.53	.84	3.76	1.23
Disorder	4.16	.042	.007
Country	146.1	<.001	.206
Disorder × Country	17.08	<.001	.029

ANCOVA: analysis of covariance; SD: standard deviation.

Age and education were used as covariates.

Russian participants endorsed ‘Stressful Life Event’, ‘Work-Related Stress’ and ‘Problems with Partner/Family’ as a cause for both Depression and Schizophrenia more often than their American counterparts. American participants endorsed ‘Chemical Imbalance’ as a cause for both Depression and Schizophrenia more often than their Russian counterparts. A disorder by country interaction suggested that this difference was more pronounced for Depression than Schizophrenia. American participants endorsed ‘Brain Disease’ and ‘Hereditary Defect’ as causes for Depression more often than their Russian counterparts. A disorder by country interaction suggested that both ‘Brain Disease’ and ‘Hereditary Defect’ were endorsed less often in Russia than in the United States. This difference was more pronounced for Depression than Schizophrenia.

Help-seeking preferences

Overall, psychiatrists were endorsed as a source of help more often for Schizophrenia than for Depression in both countries (see Table 5). Compared with Russian participants, US participants endorsed psychiatrists more frequently for Depression. The disorder by country interaction suggested that psychiatrists were less often endorsed in Russia, although this difference was not apparent for Schizophrenia. Overall, psychotherapists were endorsed as a source of help more often for Schizophrenia than for Depression in both countries. American participants endorsed psychotherapists as a source of help more often than their Russian counterparts. There was no disorder by country interaction. Compared with Russian participants, ‘Doctor/GP’ was more frequently endorsed by US participants. The disorder by country interaction suggests that ‘Doctor/GP’ received more endorsements for Schizophrenia in the United States than Depression and were endorsed more often for Depression than for Schizophrenia in Russia.

Table 5.

ANCOVA for professional help-seeking beliefs for depression and schizophrenia in United States and Russia.

	F	p	$η_{p}^{2}$	Depression				Schizophrenia
				M_US	SD_US	M_Russia	SD_Russia	M_US	SD_US	M_Russia	SD_Russia
Professional help-seeking
Psychiatrist				4.33	0.79	3.73	1.32	4.77	0.52	4.73	0.64
Disorder	7.12	.008	.013
Country	30.77	<.001	.52
Disorder × Country	48.13	<.001	.079
Psychotherapist				4.22	0.95	3.94	1.26	4.58	0.86	4.34	1.12
Disorder	25.68	<.001	.044
Country	14.44	<.001	.025
Disorder × Country	0	.993	<.001
Doctor/GP				3.83	1.09	3.37	1.20	4.09	1.23	3.25	1.45
Disorder	17.72	<.001	.031
Country	47.57	<.001	.078
Disorder × Country	13.66	<.001	.024

ANCOVA: analysis of covariance; GP: general practitioner; SD: standard deviation.

Age and education were used as covariates.

‘Someone They Trust’ was the most endorsed source of help in both countries, with Americans endorsing it more for Depression than their Russian counterparts (see Table 6). A disorder by country interaction suggested that although Russians had endorsed ‘Someone They Trust’ less often than Americans, this difference was more pronounced for Depression than Schizophrenia. Compared with Russian participants, ‘Self-Help Group’ was more strongly endorsed as a source of help among US participants. A disorder × country interaction suggested that this difference was more pronounced for Depression. Compared with Russian participants, ‘Enlisting the help of a Religious Leader’ was more strongly endorsed by US participants. A disorder by country interaction suggested that this difference was more pronounced for Depression than Schizophrenia. In addition, compared with Russian participants, ‘The Internet’ was more strongly endorsed as a source of help among US participants.

Table 6.

ANCOVA for lay help-seeking beliefs for depression and schizophrenia in United States and Russia.

	F	p	$η_{p}^{2}$	Depression				Schizophrenia
				M_US	SD_US	M_Russia	SD_Russia	M_US	SD_US	M_Russia	SD_Russia
Lay help-seeking
Someone they trust				4.27	0.85	3.96	1.08	3.63	1.27	3.55	1.3
Disorder	3.05	.081	.005
Country	8.47	.004	.015
Disorder × Country	4.52	.034	.008
Self-help group				3.63	0.99	2.92	1.14	2.82	1.33	2.68	1.37
Disorder	0.004	.948	<.001
Country	30.67	<.001	.52
Disorder × Country	18.87	<.001	.033
Religious leader				3.01	1.14	2.21	1.22	2.29	1.24	1.88	1.22
Disorder	0.58	.447	.001
Country	33.98	<.001	.057
Disorder × Country	13.45	<.001	.023
By himself				1.59	0.92	2.08	1.28	1.3	0.69	1.44	0.91
Disorder	3.59	.058	.006
Country	19.51	<.001	.034
Disorder × Country	14.55	<.001	.025
Internet				2.18	1.06	1.81	1.03	1.69	0.97	1.47	0.98
Disorder	4.42	.036	.008
Country	16.25	<.001	.028
Disorder × Country	1.89	.17	.003

ANCOVA: analysis of covariance; SD: standard deviation.

Age and education as covariates.

While Americans endorsed almost every source of help at higher rates than Russians, the one source of help that Russians endorsed more strongly than their American counterparts was for the person in the vignette do something about the problem ‘By Himself’ (see Table 6). The disorder by country interaction suggested that doing something about the problem ‘By Himself’ was more strongly endorsed in Russia than in the United States. This difference was more pronounced for Depression than Schizophrenia.

Weak will and immoral lifestyle

ANCOVA tests found a significant difference between how Russian and US participants responded to items ‘weak will’ and ‘immoral lifestyle’ as causes of these disorders. Russian participants (M=2.68, SD=1.331) endorsed the view that people with Depression are ‘Weak Willed’ more strongly than their American counterparts (M=1.76, SD=1.036), F(1, 564)=89.00, p<.001, η p 2 = .136. Russian participants (M=2.07, SD=1.143) also endorsed the view that people with Depression lead an ‘Immoral Lifestyle’ more often than their American counterparts (M=1.78, SD=.992), F(1, 566)=19.83, p<.001, η p 2 = .034.

Discussion

As hypothesized, participants tended to endorse the view that Depression is caused by psychosocial factors, such as work-related stress and problems with partner or family compared with Schizophrenia. In contrast, participants tended to attribute biological factors, such as a hereditary defect or brain disease, to Schizophrenia. ‘Stressful life event’ was endorsed as the highest ranking cause of Depression and was endorsed significantly more often than for Schizophrenia. Significant differences also emerged between countries. As expected, Russian participants more strongly endorsed psychosocial causes of the two disorders, while US participants favored biological causes. Moreover, Russian participants rated psychosocial stressors as the leading cause of Depression, but participants in the United States chose ‘chemical imbalance’ as the leading cause. Russians were also more likely to view depression as a result of ‘weak will’ or ‘immoral lifestyle’.

Psychological and social explanations

Clearly, a perspective that emphasizes negative traits such as ‘weak will’ or ‘immoral lifestyle’ may exacerbate stigma. More generally, Russians viewed psychosocial stress (e.g. problems at work, family and life stress) as the cause of mental illness more than biology, but these other explanations may not invariably be linked to negative preconceptions about mental illness. Instead, this pattern of findings may be suggestive of differing cultural beliefs about psychosocial as opposed to biological explanations of behavior. Americans are likely more exposed to pharmaceutical marketing about mental illness, which has been considered to be controversial on several grounds, especially given that ‘chemical imbalance’ theories promoted by the industry have been judged to be scientifically inaccurate (e.g., France, Lysaker, & Robinson, 2007; LaCasse & Leo, 2015). In contrast, such marketing may be less prevalent in Russia and other European countries. The models promulgated in the US potentially compete with psychosocial explanations (e.g. there is little space for family problems in simplified ‘chemical imbalance’ theories). Second, notably even published abstracts in a European (British) journal may be more likely to acknowledge psychosocial explanations in their attempts to understand psychosis, compared with their American counterparts who place more emphasis on biological correlates (e.g. Jarvis et al., 2015). While it is doubtful that journal editors influence public opinion, it is certainly possible that these patterns may be partly due to bottom-up cultural disparities in how psychosis is broadly perceived in different regions of the World (see also Jarvis, 2007). Finally, the tendency to emphasize internal attributes as explanatory in contrast to context is more common in Western cultural settings (e.g. Miller, 1984). Our findings are consistent with such differences.

Dangerousness

As in previous research, the attitudes of participants in this study toward those with Schizophrenia were quite negative (Schomerus et al., 2012), although Russian participants rated ‘dangerousness’ higher than their US counterparts for Schizophrenia. Some research indicates that individuals with severe mental illness may indeed be at higher odds of becoming a victim or perpetrator of crime (Teplin, McClelland, Abram, & Weiner, 2005), but the vast majority of those with mental illness do not pose a threat (Elbogen & Johnson, 2009). Furthermore, the association between violence and psychosis may be accounted for largely by co-occurring substance abuse (Fazel, Gulati, Linsell, Geddes, & Grann, 2009).

Help-seeking

Differences in help-seeking beliefs also emerged between countries. US participants recommended seeing a psychiatrist for both diagnoses. Russians, by contrast, endorsed all help-seeking significantly less often than US participants. While Americans endorsed every other item more strongly than Russians, Russian participants endorsed ‘by himself’ as a way to get help for Depression significantly more than US participants. Perhaps this unexpected difference arose because Russians did not consider the person depicted in the vignette as having a mental illness or because of the associated stigma in seeking any kind of help, given that Americans still endorsed non-professional helpers (e.g. friends) more than Russians. Russians are more likely to see Depression as a personal weakness and immoral lifestyle (see above), thereby likely discouraging people from sharing their difficulties. Relatedly, lower levels of institutional trust among Russians may partly explain our findings (see Jurcik et al., 2013). These differences in help-seeking may also reflect differences in definitions of what constitutes a mental disorder that requires treatment. Although the clinical syndrome we label Depression is likely universal (Heine, 2015), the expression of distress or the threshold for what may be considered ‘normal’ may vary between cultural groups (e.g. Chentsova-Dutton, Tsai, & Gotlib, 2010). Russians thus likely have different emotion norms with respect to expressing sadness or criteria for what is severe enough to warrant clinical attention than Americans do (see Jurcik et al., 2013).

Limitations and strengths

A number of limitations of this study warrant consideration. First, this study uses a convenience sample, with data collected through snowball sampling (Goodman, 1961). Most of the data were received from participants who have an account on Facebook or VKontakte. As VKontakte is the most widely used social network service in Russia, we utilized it as well as Facebook to obtain our sample. A greater proportion of adults in America may have a profile on social media than in Russia, which obviously may limit representativeness, although access to the Internet and Internet literacy is extensive in Russia (Warf, 2009). A second limitation is that the age and education of respondents is dissimilar between countries, although we statistically controlled for this difference in our analyses. Our vignette was restricted to male gender and college students were overrepresented in both samples. Finally, the Russian sample was smaller than the US sample, although our study was likely sufficiently powered given the pattern of significance.

The strengths of this study include that it is one of the very few studies conducted on MHL in Russians to date and highlights important differences with the United States that may assist with the implementation of culturally tailored psychoeducation programs. It compared two disorders that are often misunderstood. We also translated an often-used questionnaire on MHL created by Angermeyer and colleagues (Angermeyer, Matschinger, & Schomerus, 2013; Angermeyer, Millier, et al., 2013), which can now be used in the Russian context.

Implications and future directions

As recognizing the symptoms of a mental disorder can facilitate early help-seeking, we must attend to variables that can affect the actions a person takes if he or she develops a mental disorder (Jorm, 2012). This study shows that country-level and cultural differences must be considered when researching psychiatric epistemology, attitudes and help-seeking toward mental health disorders. Based on discussions with clinicians working in Russia, patients sometimes believe that depression is a chronic and untreatable illness. Prevention programs can be culturally informed and tailored to promote more positive attitudes about professional help-seeking and provide information about qualified sources of help. Sustained efforts at improving professional standards in mental health assessment and treatment may also be necessary to foster improved public trust in both countries.

Future studies will need to replicate this study using more sophisticated sampling methods. For example, a probabilistic community sampling strategy may be attempted to obtain a more representative sample by recruiting not only from the Internet but also accessing older participants. Studies could also explore perceptions of gender differences in mental illness. For instance, perhaps our participants expected the person in the vignette to be self-sufficient due to male stereotypes. Other Eastern European countries in the post-communist space deserve to be studied as well, given that relatively little is known about attitudes toward mental illness and help-seeking in this region (e.g. Poland, Czechia, Slovakia, Ukraine). Chentsova-Dotton, Tsai, and Ryder (2014) argue that because Depression is affected by biological, psychological and cultural variables, it must be explained in a way that references all factors and their interactions. We believe that this approach extends to a more complete understanding of between- and within-country public MHL.

Summary and conclusion

The following cross-cultural study on MHL showed that compared with Americans, Russians were more likely to view Depression and Schizophrenia as caused by psychosocial as opposed to biological factors. Russians believed that Depression was caused by weak-will and more likely to endorse relying on oneself for solving significant mental health problems. Americans were more likely to cite a chemical imbalance and recommend professional and lay help-seeking. Our findings further inform cultural understandings of these mental illnesses in an oft neglected national group. Patterns suggest that both groups may benefit from exposure to corrective information about Depression and Schizophrenia. More research on MHL is needed in representative samples in Eastern Europe.

Footnotes

Acknowledgements

The authors thank Klaus G Boehnke and Morteza Charkhabi for their assistance with the statistical analyses and the sociocultural laboratory at HSE for their feedback on this research project, which was part of K Nersessova’s Master’s thesis.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Karine S Nersessova

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