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DOI: 10.1177/2156869311431100 2011 1: 200 originally published online 20 December 2011Society and Mental Health

Krysia N. Mossakowski, Lauren M. Kaplan and Terrence D. HillAmericans' Attitudes toward Mental Illness and Involuntary Psychiatric Medication

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Americans’ Attitudes towardMental Illness and Involuntary

Psychiatric Medication

Krysia N. Mossakowski1, Lauren M. Kaplan2, and

Terrence D. Hill3

Abstract

This study uses data from the Mental Health Modules of the General Social Survey (1996 and 2006) to

understand why some Americans endorse the involuntary use of psychiatric medication. Results indicated

that in 1996 and 2006, 28 percent of Americans believed that people with mental illness should be forced

by law to take psychiatric medication. The belief that people with mental illness are dangerous significantly

contributed to Americans’ endorsement of this form of mandated treatment. Interestingly, the belief that

mental illness is caused by stress increased the odds of support for mandated medication in 1996 and then

reduced the odds of support in 2006. Moreover, stigmatizing preferences for social distance from those

with mental illness were no longer contributing factors in 2006. It is still imperative, however, that public

policy makers promote anti-stigma initiatives to reduce barriers to psychiatric treatment and counteract

the public’s lingering fear of people with mental illness.

Keywords

mental disorders, drug therapy, stigma, treatment

A controversial issue that warrants further research is

how society should treat people with mental illness.

Deinstitutionalization signified a major societal

change in how people with mental health problems

were treated medically, which included an emphasis

on short-term inpatient and outpatient treatment, com-munity mental health services, and the use of psychi-

atric medications (Crilly 2008; Lamb and Bachrach

2001). Despite deinstitutionalization, involuntary psy-

chiatric treatment continues to be a source of consid-

erable debate in the United States and internationally

(Agnetti 2009; Crilly 2008; Monahan et al. 2001,

2005; Perry et al. 2007; Pescosolido et al. 1999;

Pescosolido, Fettes, et al. 2007). The current study

focuses on why some Americans endorse the involun-

tary use of prescription medications for the treatment

of mental illness. National trends indicate that sincethe mid-1990s the use of prescribed psychiatric med-

ications has dramatically increased, especially for

depression (e.g., the use of antidepressants has more

than doubled), while the use of psychotherapy has

decreased (Mojtabai and Olfson 2008; Olfson and

Marcus 2009).

The use of prescribed psychiatric medication is

considered to be one of the key ways to help peo-

ple with mental illness to socially function in thecommunity and avoid institutionalization in hospi-

tals or prisons. For example, court-ordered outpa-

tient commitment involves mandating persons

1University of Hawaii at Manoa, Honolulu, HI, USA2 J.W. Goethe-Universitat Frankfurt a.M., Frankfurt am

Main, Germany3Florida State University, Tallahassee, FL, USA

Corresponding Author:

Dr. Krysia Mossakowski, Department of Sociology,University of Hawaii at Manoa, Saunders Hall, Room 215,

2424 Maile Way, Honolulu, HI, 96822

Email: [email protected]

Society and Mental Health1(3) 200–216

American Sociological Association 2011

DOI: 10.1177/2156869311431100http://smh.sagepub.com

at University of Huddersfield on April 25, 2014smh.sagepub.comDownloaded from







with mental illnesses to adhere to prescribed psy-

chiatric treatment as a condition for allowing them

to remain in the community as opposed to being

involuntarily hospitalized (Monahan et al. 2001).

In the context of the criminal justice system, de-

fendants with mental illnesses can be ordered by

judges and probation officers to comply with psy-

chiatric treatment to avoid long-term incarceration

or hospitalization (Monahan et al. 2001). ‘‘In

these contexts, judicial authority to impose sanc-

tions and curtail freedom provides the leverage

for inducing treatment adherence in the commu-

nity’’ (Monahan et al. 2001:1200).

There is evidence that assisted outpatient treat-

ment in the community improves compliance with

psychiatric medication and social functioning and

minimizes subsequent hospital readmission, violent

behavior, suicide risk, and arrests among people

with severe mental illnesses (Hiday 2003; Link,

Castille, and Stuber 2008; Link et al. 2011; Phelan

et al. 2010; Swartz et al. 2010). A lack of compli-

ance with prescribed psychiatric medication is

a common cause of repeated involuntary hospitaliza-

tions, and it can result in the loss of social welfare

benefits (e.g., income support and subsidized hous-

ing), which could ultimately lead to homelessness

(Monahan et al. 2001, 2005). Moreover, legally

mandated adherence to psychiatric medication and outpatient commitment are especially beneficial for

people whose medical decisions and awareness

can be impaired by symptoms of mental illness

(Monahan et al. 2001, 2005). Despite these long-

term benefits, opponents contend that any psychiat-

ric treatment that limits people’s civil liberties is

coercion (Allen and Smith 2001).

Sociological research has revealed that whether

Americans endorse the legal coercion of psychiatric

medication depends on the type of mental illness.

Pescosolido and colleagues’ (1999) groundbreakingstudy used data from the 1996 Mental Health

Module of the General Social Survey (GSS) and

found that Americans more strongly supported forc-

ing people by law to take medication for schizophre-

nia (42.1 percent) and drug dependence (36.8

percent) than for alcohol dependence (24.5 percent)

and depression (24.3 percent). Furthermore, people

with schizophrenia and drug dependence were per-

ceived to be more dangerous and less competent

to make treatment decisions than people with

depression (Pescosolido et al. 1999). Pescosolidoand colleagues (1999) found that perceived danger-

ousness was a significant predictor of the public’s

support for coerced psychiatric treatment, including

prescription medication. In the United States, people

diagnosed with mental illness can be forced by law

to take prescribed psychiatric medications or be hos-

pitalized if they are deemed to be dangerous to

others, themselves, or property (Crilly 2008).

Stigma Theory

Although some types of mental illnesses, such as

depression, are not as stigmatized as others (e.g.,

schizophrenia and drug dependence), evidence sug-

gests that the stigma surrounding mental illness en-

dures in the United States (Corrigan et al. 2003;

Link et al. 1999; Martin, Pescosolido, and Tuch

2000; Martin et al. 2007; Perry et al. 2007;

Pescosolido, Perry, et al. 2007; Phelan 2005; Phelan

et al. 2000; Schnittker 2000). The stigma of mental

illness involves attitudes and behaviors that reject,

exclude, and disapprove based on limited knowledge,

fear, and prejudice (Link and Phelan 2001). The pub-

lic’s concern that people suffering from symptoms of

mental illness will likely be dangerous to others or to

themselves is a central element of stigma (Martin

et al. 2007; Payton and Thoits 2011).

Sociologists have also drawn our attention to

the pervasiveness of stigma by examining the pub-

lic’s discriminatory preferences for social distancefrom those with mental illness (Corrigan et al.

2003; Link et al. 1999; Martin et al. 2000, 2007;

Perry et al. 2007; Pescosolido, Perry, et al. 2007;

Phelan 2005; Phelan et al. 2000; Schnittker

2000). These preferences for social distance can,

for example, inspire resistance to having someone

with a mental illness live next door or become

a friend, family member, or work colleague. It re-

mains to be determined whether preferences for

social distance contribute to Americans’ endorse-

ment of the involuntary use of psychiatric medica-tion and help to explain why certain types of

mental illness matter more or less.

Link and Phelan’s (2001) theorization about

stigma not only highlights how society treats people

diagnosed with mental illness by separating ‘‘us’’

from ‘‘them,’’ but also encourages social scientists

to uncover other social consequences of stigma.

Link and Phelan move beyond earlier sociological

theories about mental illness as a stigmatized attri-

bute of the individual. They contend that stigmatiza-

tion is a social process that occurs in the context of established power dynamics. ‘‘Thus, stigma exists

when elements of labeling, stereotyping, separation,

status loss, and discrimination occur together in

Mossakowski et al. 201








a power situation that allows them’’ (Link and

Phelan 2001:377).

A potential social consequence of stigmatization

is the abrogation of civil rights via coercion.

Coercion involves the legal use of power to involun-

tarily treat individuals diagnosed with mental illness

(Link et al. 2008). Our knowledge remains limited

about the relationship between the stigma of mental

illness and the use of coercion in psychiatric treat-

ment (Link et al. 2008). According to stigma theory,

it is crucial that we explore whether the public’s

stigmatizing beliefs about mental illness shape opin-

ions about whether the medical institution, a power-

ful agent of social control, should use legal coercion

for psychiatric treatment in general and prescription

medication use in particular. What also warrants

inquiry is whether stigmatizing preferences for

social distance and perceptions of dangerousness

are mechanisms that help to explain the relationship

between the type of mental illness and public sup-

port for involuntary psychiatric medication use.

Our study addresses these gaps in our knowledge

about the ramifications of stigmatizing beliefs.

Changes in Public Attitudes

Recent studies that used data from the 1996 and

2006 GSS Mental Health Modules revealed thatalthough some public beliefs about mental illness

have changed, others have not (Payton and Thoits

2011; Pescosolido et al. 2010; Schnittker 2008).

For example, stigmatizing preferences for social dis-

tance and perceptions of dangerousness did not

decrease significantly regarding schizophrenia,

depression, and alcohol dependence (Payton and

Thoits 2011; Pescosolido et al. 2010; Schnittker

2008). Yet the neurobiological explanation of mental

illness, such as attributing the condition to a chemical

imbalance in the brain or to genetics, has gained more public support over time (Pescosolido et al.

2010; Schnittker 2008). While the environmental

explanation, the belief that mental illness is caused

by stressful circumstances, has remained stable

over the same period (Schnittker 2008), fewer

Americans seem to believe that one’s upbringing

could cause schizophrenia (Schnittker 2008).

Some have claimed that genetic and chemical

imbalance explanations are not sufficient to counter-

act stigma, especially the public’s fear that people

with mental illness are likely to be dangerous(Hinshaw and Cicchetti 2000; Pescosolido et al.

2010; Phelan 2005; Schnittker 2008). In recent dec-

ades, the news media and direct-to-consumer (DTC)

advertising by pharmaceutical companies have

emphasized that genetics and a chemical imbalance

in the brain cause mental illness (Conrad 2001; Leo

and Lacasse 2008). DTC advertising of psychiatric

medications is a powerful force of medicalization

(Payton and Thoits 2011). Medicalization involves

the transformation of personal problems into medi-

cal problems (e.g., mental illness), and the medical

institution is given the authority to socially control

those deviant thoughts, feelings, and behaviors,

such as by prescribing psychiatric medications

(Conrad 2007). Sociologists need to investigate

whether the medicalized view of mental illness,

such as the popular beliefs that genetics and a chem-

ical imbalance cause mental illness, fuels

Americans’ support for involuntary psychiatric med-

ication and whether it helps to explain why the type

of mental illness contributes to the endorsement of

this form of psychiatric treatment.

Inspired by theories about stigma and medical-

ization, our study advances the literature by

exploring whether beliefs about the causes of

mental illness and the stigma of mental illness

help to explain why the type of mental illness is

a key determinant of Americans’ support for the

involuntary use of psychiatric medication. More spe-

cifically, we use data from the 1996 and 2006 GSS

Mental Health Modules to assess our conceptualmodel (see Figure 1) and the following specific

research questions: (1) To what extent did

Americans endorse forcing people by law to use pre-

scription medications for the treatment of mental ill-

ness in 1996 and 2006? (2) Did the type of mental

illness, beliefs about the causes of mental illness,

perceptions of dangerousness, and preferences for

social distance contribute to Americans’ endorse-

ment for the involuntary use of psychiatric medica-

tion in 1996 and 2006? (3) Do beliefs about the

causes of mental illness and stigma help to mediateor explain the relationship between the type of men-

tal illness and support for involuntary psychiatric

medication? We also control for the respondent’s

gender, age, race/ethnicity, socioeconomic status,

region of U.S. residence, and religious attendance,

which are important sociodemographic factors that

influence public attitudes about mental illness

(Pescosolido et al. 1999).

METHOD

This study used data from the 1996 and 2006

Mental Health Modules of the U.S. General

202 Society and Mental Health 1(3)








Social Survey, conducted by the National

Opinion Research Center. The GSS uses a full

probability sample of noninstitutionalized adults.

This face-to-face survey secured oral informed consent at the time of the interviews. Randomly

selected subsamples of GSS respondents

received the special topical modules on mental

health in 1996 ( N = 1,444) and in 2006 ( N =

1,523). Each respondent was randomly presented

a vignette that described a fictional individual

that exhibited symptoms of mental illness or no

mental health problem (please see Appendix A

for transcripts of the vignettes). The 2006

Mental Health Module replicated the 1996

vignette questions. Due to the split ballot designand listwise deletion, the sample was reduced to

984 in 1996 and to 1,195 in 2006. Sensitivity

analyses (available on request) were conducted

to confirm that the missing data were not biasing

our findings. The data were also weighted to

account for different sampling procedures in

1996 and 2006.

Measures. Endorsement of the involuntary use

of psychiatric medication was the focal outcome

in 1996 and 2006. It assessed whether the respon-

dent believed that the person depicted in thevignette should be forced by law to take a prescrip-

tion medication to control his or her behavior. The

responses were dichotomous (0 = no, 1 = yes).

Logistic regression analyses using SPSS were

conducted.

Variables for the different mental health prob-

lems referred to in the vignettes included depres-sion, schizophrenia, alcohol dependence, and

drug dependence in 1996. In 2006, the drug

dependence vignette was not included. The vi-

gnettes where respondents were presented with

a depiction of an individual with problems that

were not consistent with the Diagnostic and

Statistical Manual of Mental Disorders ( DSM-IV ;

American Psychiatric Association 1994) diagnostic

criteria were coded as ‘‘no mental health prob-

lem,’’ which was the reference category in our

regression analyses. The demographic characteris-tics of the person in the vignette varied and were

presented randomly to respondents. We controlled

for vignette gender (1 = female), race/ethnicity (1

= white), and education (1 = college).

Variables were constructed for beliefs about the

causes of the individual’s symptoms in the vignette,

which included his or her own bad character,

a chemical imbalance in the brain, the way (he or

she) was raised, stressful circumstances in his or

her life, a genetic or inherited problem, and

God’s will, with responses ranging from 1 (not at all likely) to 4 (very likely). These questions were

not mutually exclusive, and the respondents could

select multiple causal attributions.

Type of mental

illness

Sgma: perceived

dangerousness and

preferences for

social distance

Endorsement of

involuntary

psychiatric

medicaon

Beliefs about the

causes of mental

illness

Figure 1. Conceptual model









The measures of stigma included perceived

dangerousness and preferences for social distance.

In 1996 and 2006, perceived dangerousness was

assessed with two variables indicating how likely

respondents believed that the person depicted in

the vignette ‘‘would do something violent toward

other people’’ (violent to others) or to ‘‘him/her-

self’’ (violent to self). Responses ranged from 1

(not likely at all ) to 4 (very likely). Public attitudes

were assessed with six items in a mean index in

1996 (Cronbach’s alpha = .868) and in 2006

(Cronbach’s alpha = .861) indicating stigmatizing

preferences for social distance from the person de-

picted in the vignette. Supplementary factor anal-

yses confirmed that the items loaded on one

factor. This variable measured unwillingness (1

= definitely willing , 2 = probably willing , 3 =

probably unwilling , 4 = definitely unwilling ) to

have someone with a mental illness move next

door, start working closely with you on a job,

marry into your family, spend an evening socializ-

ing with you, become your friend, and have

a group home for people like [NAME from the

vignette] opened in your neighborhood.

We also control for sociodemographic charac-

teristics of the respondent (please see Table 1 for

descriptive statistics). These variables included

age (in continuous years), gender (1 = female,0 = male), race/ethnicity (dummy variables for

black and other, with non-Hispanic white as the

reference category), years of education, employ-

ment status (1 = employed full- or part-time),

region of residence (1 = Southerner), and religious

attendance, with responses that ranged from

0 (never) to 8 (more than once a week).

Analysis strategy. Our analysis strategy begins

with the descriptive statistics shown in Table 1,

which compare the variables in 1996 and 2006.

In Table 2, four logistic regression models explorethe extent to which the type of mental illness, be-

liefs about the causes of mental illness, perceived

dangerousness, and preferences for social distance

influence the public’s support for the use of invol-

untary psychiatric medication in 1996. We are

especially interested in whether the effects of the

types of mental illnesses depicted in the vignettes

are mediated or explained by beliefs about the

causes of mental illness and/or stigma (i.e., per-

ceived dangerousness and preferences for social

distance). Logistic regression models in Table 3similarly examine the extent to which these fac-

tors contribute to the public’s support for involun-

tary medication in 2006. All models adjust for the

respondents’ age, gender, race/ethnicity, educa-

tion, employment status, region of residence, and

religious attendance. The final stage of the analy-

ses includes a supplemental assessment (see

Appendix B) of whether the effects of our focal

variables change over time by estimating a series

of interactions with survey year.

RESULTS

Table 1 shows the descriptive statistics, including

the means, standard deviations, and ranges.

Forcing people by law to use prescription medica-

tion for the treatment of mental illness was

endorsed by approximately 28 percent of the re-

spondents in 1996 and in 2006. This stability in

public response is surprising because it occurred

during a period when the use of psychiatric med-

ications significantly increased (Mojtabai and

Olfson 2011). The GSS respondents generally

agreed that it is likely that stress and a chemical

imbalance in the brain cause mental illness to

a somewhat greater extent than the way the person

was raised, a genetic/inherited problem, the per-

son’s bad character, and God’s will. Compared

to 1996, the beliefs that mental illness is caused

by a chemical imbalance in the brain and geneticsincreased in 2006, whereas the belief that mental

illness is attributed to bad character decreased

slightly. The public’s support also diminished

somewhat for preferences for social distance and

perceptions that people with mental illness are

dangerous to themselves and to others.

According to independent samples t tests, these

small changes in the public’s general beliefs about

the causes of mental illness and stigma are statis-

tically significant.

1996 GSS Mental Health Module. Logisticregression models in Table 2 examined the extent

to which the type of mental illness, beliefs about

the causes of mental illness, perceived dangerous-

ness, and preferences for social distance influ-

enced the public’s endorsement of the

involuntary use of psychiatric medication in

1996. All models adjusted for the respondents’ so-

ciodemographics (not shown). In model 1, the re-

spondents more strongly endorsed the legal

coercion of medication for schizophrenia (odds

ratio [OR] = 5.35; p \ .001) and drug dependence(OR = 4.57; p \ .001) than for alcohol depen-

dence (OR = 2.76; p \ .001) and depression

(OR = 2.02; p \ .05). Model 2 added the different









attributions of the causes of mental illness to the

equation. Results in model 2 indicated that the be-

liefs that mental illness is caused by stress (OR =

1.29; p \ .05), bad character (OR = 1.21; p \

.05), and a chemical imbalance in the brain (OR

= 1.20; p \ .05) increased the odds of support

for coerced psychiatric medication. Moreover,

the relationship between depression and coerced

medication was no longer statistically significant

in model 2, which suggested that beliefs about

the causes of mental illness were mediating mech-

anisms that helped to explain why.

Model 3 additionally controlled for perceived

dangerousness, a key dimension of stigma.

Schizophrenia, drug dependence, and attributing

mental illness to stress continued to be contribut-

ing factors for this form of mandated treatment.

Alcohol dependence was no longer a statistically

significant predictor in model 3, which suggested

that perceived dangerousness was a mediating

mechanism. Bad character and chemical imbal-

ance were also no longer statistically significant

in model 3. Therefore, the effects of these causal

attributions were also explained by perceived

Table 1. Descriptive Statistics: 1996 and 2006 General Social Survey Mental Health Modules

1996a 2006b

Variables M SD M SD Range

Endorsed involuntary medication 0.276 0.447 0.276 0.447 0-1Vignette characteristics

Non-Hispanic white 0.336 0.473 0.330 0.470 0-1Female 0.525* 0.500 0.488 0.500 0-1College 0.328* 0.469 0.351 0.477 0-1Depression 0.208*** 0.406 0.273 0.446 0-1Schizophrenia 0.208* 0.406 0.236 0.425 0-1Alcohol dependence 0.197*** 0.398 0.246 0.431 0-1Drug dependence 0.197 0.398 — — 0-1No mental health problem 0.190* 0.393 0.245 0.430 0-1

Causes of mental illness

Bad character 2.400*

1.010 2.350 0.983 1-4Chemical imbalance 2.699*** 0.972 2.976 0.853 1-4Way he or she was raised 2.445 0.913 2.428 0.902 1-4Stressful circumstances 3.233 0.754 3.269 0.697 1-4Genetics 2.427*** 0.931 2.680 0.863 1-4God’s will 1.605 0.870 1.554 0.808 1-4

Perceived dangerousnessViolent to self 2.962*** 0.900 2.839 0.878 1-4Violent to others 2.580*** 0.937 2.434 0.850 1-4

StigmaPreferences for social distance 2.537*** 0.752 2.399 0.682 1-4

Respondent demographics

Female 0.532 0.499 0.549 0.498 0-1Non-Hispanic white 0.811*** 0.392 0.752 0.432 0-1Age 43.070** 16.167 44.745 16.712 18-89Years of education 13.384* 2.891 13.708 2.732 0-20Employed 0.696** 0.460 0.651 0.477 0-1Southern residence 0.259* 0.438 0.280 0.449 0-1Rural residence 0.160 0.367 0.174 0.379 0-1Religious attendance 3.653 2.637 3.472 2.753 0-8

Notes: Independent samples t tests comparing 1996 to 2006: *p \ .05; **p \ .01; ***p \ .001.a. For 1996, the sample size ranges from 1,168 to 1,342 because of missing data.b. For 2006, the sample size ranges from 1,282 to 1,364 because of missing data.









mental illness are dangerous to themselves on sup-

port for the legal coercion of psychiatric medica-

tion was stronger among whites than racial/

ethnic minorities in 1996. In 2006, the effect of

attributing mental illness to genetics on support

for coerced medication was also stronger among

whites.

Changes over time. We formally assessed

whether the effects of our focal variables changed

over time by estimating a series of interactions

with survey year. The results of this supplemental

analysis (see Appendix B) revealed nonsignificant

interaction terms for several vignette characteris-

tics (gender, race, education, and alcohol depen-

dence), all beliefs about the causes of mental

illness, and perceived dangerousness to self and

others. However, we observed three statistically

significant interactions. The schizophrenia

vignette increased the odds of endorsement of

coerced psychiatric medication, and this pattern

was more pronounced in 2006 than in 1996 (OR

= 2.726; p \ .001). The significant interaction

for the depression vignette (OR = 2.866; p \

.001) also suggested that this condition was

a stronger contributing factor for endorsement of

forced medication in 2006 than in 1996.

Although preferences for social distance tended

to increase the odds of endorsement of forced medication, this pattern was weaker in 2006 than

in 1996 (OR = 0.733; p \ .05). Finally, by adding

survey year to our regression models, we were

also able to test whether endorsement for the legal

coercion of psychiatric medication changed over

time. The nonsignificant effect of survey year

indicated that endorsement for this form of man-

dated treatment was similar in 1996 and 2006.

DISCUSSION

In the United States and other countries, the use of

prescribed psychiatric medications without con-

sent remains a contentious issue (Agnetti 2009;

Crilly 2008; Monahan et al. 2001, 2005; Perry et

al. 2007; Pescosolido et al. 1999; Pescosolido,

Fettes, et al. 2007). To what extent do

Americans endorse the involuntary use of pre-

scription medication for the treatment of mental

illness? In 1996 and 2006, we found that more

than one in four Americans believed that peoplewith mental illness, as depicted in the GSS vi-

gnettes, should be forced by law to take psychiat-

ric medication. This surprisingly stable trend

occurred in the context of greater use of psychiat-

ric drugs, including reasons beyond diagnostic

considerations and possibly as enhancers of per-

sonal and social well-being (Mojtabai and

Olfson 2011). Although the use of prescribed psy-

chiatric medications has grown, this did not seem

to translate into stronger support for the use of

legal coercion for this form of treatment.

How have Americans’ beliefs about mental

illness changed from 1996 to 2006? Consistent

with prior research, our descriptive statistics

indicated more public support for neurobiologi-

cal explanations, which include attributing

mental illness to genetics and a chemical imbal-

ance in the brain (Pescosolido et al. 2010;

Schnittker 2008). Regarding stigma, in the aggre-

gate the public’s average levels on the preferen-

ces for social distance scale diminished slightly,

and the average levels of perceived dangerous-

ness of people with mental illness has weakened

somewhat. Pescosolido and colleagues’ (2010)

recent study that used data from the 1996 and

2006 GSS revealed that the public’s level of

stigma as indicated by each different preference

for social distance and perception of dangerous-

ness had not changed significantly pertaining

to schizophrenia, depression, and alcohol

dependence. An earlier U.S. study found that perceptions of dangerousness had gained more

public support in 1996 compared to 1950

(Phelan et al. 2000). In 1999, the reduction of

stigma was one of the main public health policy

goals in the first report to the U.S. Surgeon

General on mental illness (U.S. Department of

Health and Human Services 1999). Pescosolido

and colleagues (2010) warn that anti-stigma cam-

paigns need to redirect their focus away from the

claim that mental illness is a genetic brain disor-

der and emphasize the abilities, competencies,and social inclusion of people with mental

illnesses.

In line with prior research, our results further

suggested that the public more strongly believes

that schizophrenia should be coercively medicated

than drug dependence, alcohol dependence, and

depression (Pescosolido et al. 1999). Those with

schizophrenia represent a small group, approxi-

mately 1 percent of the U.S. population (National

Institutes of Mental Health 2011). Research is nec-

essary to better understand the public’s awarenessof prescription medications for drug and alcohol

dependence. Another direction for future research

is whether the severity of the symptoms of mental









illness may affect the public’s support for coerced

medication.

One of the new contributions of this study is an

investigation of several mediating mechanisms

that help explain the relationship between the

type of mental illness and public support for the

involuntary use of prescribed medications for the

treatment of mental illness. Essentially, we find

that the public’s beliefs about the causes of mental

illness and stigma are crucial explanatory factors.

In 1996, we found that beliefs about the causes of

mental illness mediated the relationship between

depression and public support for involuntary psy-

chiatric medication. Perceptions of dangerousness

were mediators for the relationship between alco-

hol dependence and involuntary medication. In

addition, the influence of drug dependence was

explained by the other element of stigma, prefer-

ences for social distance. In 2006, the association

between depression and involuntary medication

was also explained by perceived dangerousness.

Furthermore, beliefs about the causes of mental

illness explained the relationship between alcohol

dependence and involuntary medication.

Together, these findings advance our understand-

ing of the different reasons why the type of mental

illness matters.

Drawing on stigma theory, our study further contributes to the literature by examining the

extent to which the Americans’ preferences for

social distance from people with mental illness

and their beliefs that those with mental illness

are dangerous influence their support of involun-

tary psychiatric medication in 1996 and 2006.

The few studies on the public’s views of the invol-

untary use of psychiatric medication (Perry et al.

2007; Pescosolido et al. 1999; Pescosolido,

Fettes, et al. 2007; Schnittker 2008) did not exam-

ine the influence of preferences for social dis-tance. Our 1996 results indicated that

preferences for social distance and perceived dan-

gerousness to self increased public support for

legally coerced psychiatric medication. Yet, in

2006, preferences for social distance no longer

had an influence on public endorsement of

coerced medication. This suggests that the public

may have become less likely to endorse this

form of psychiatric treatment for the purpose of

avoiding or excluding people with mental ill-

nesses. This could be evidence that some anti-stigma initiatives that targeted discrimination

had an effect during that time period. In 2006,

however, both perceived dangerousness to self

and to others contributed to the public’s willing-

ness to use coerced medication. Moreover, per-

ceived dangerousness to others increased the

public’s endorsement of this form of treatment

to a greater extent than perceived dangerousness

to self. In 1996, perceived dangerousness to others

did not have an influence. It is possible that the

influence of perceptions of dangerousness on the

public’s acceptance of coercive psychiatric treat-

ment may be growing. Perhaps, heightened media

coverage of violence by persons with a mental ill-

ness has had an impact.

Our study suggests that perceived dangerous-

ness is an aspect of stigma that still needs to be ad-

dressed by anti-stigma campaigns. It is clear that

the public’s stigmatizing fear that those with men-

tal illness will be violent has not disappeared.

Similarly, Pescosolido, Fettes, and colleagues’

(2007) study that used data from the 2002

National Stigma Study found that perceived dan-

ger to others predicted Americans’ support for

coerced medication for children. More studies

need to identify how beliefs about mental illness,

such as attention deficit hyperactivity disorder and

the medicalization of deviant behaviors in the

classroom, motivate Americans’ willingness to

have their children use psychiatric medications

(McLeod et al. 2004, 2007; Perry et al. 2007;Pescosolido, Fettes, et al. 2007; Pescosolido,

Perry, et al. 2007). According to stigma theory

(Link and Phelan 2001), Americans’ beliefs about

mental illness have various social consequences

for the individual and social institutions (e.g.,

medicine and education) that need to be discov-

ered to illuminate the larger power dynamics

that facilitate both individual-level and struc-

tural-level discrimination.

Do beliefs about the causes of mental illness

contribute to Americans’ support for the legalcoercion of psychiatric medication? Our results

in 1996 indicated that attributing mental illness

to stress, a chemical imbalance in the brain, and

a person’s bad character increased the odds of

support for the involuntary use of psychiatric

medication, regardless of the type of mental ill-

ness. The positive association between attributing

mental illness to stress and endorsement of

coerced medication was the most robust, net of

all control variables. In 2006, genetics and bad

character increased support for involuntary medi-cation, but those associations were explained by

perceived dangerousness. In contrast to 1996,

attributing mental illness to stress predicted









cause could have contributed to the increase in

antidepressant use (Olfson and Marcus 2009).

From 1996 to 2005, there was a dramatic increase

in the use of antidepressant medication in the

United States, from approximately 13.3 million

to 27 million people (Olfson and Marcus 2009).

Furthermore, national trends indicate that there

has been a significant reduction in the utilization

of psychotherapy: 44.4 percent of visits to psy-

chiatrists involved psychotherapy in 1996-1997

and only 28.9 percent of visits involved psycho-

therapy in 2004-2005 (Mojtabai and Olfson

2008). A recent meta-analysis of numerous stud-

ies, however, provides compelling evidence of

the effectiveness of long-term psychotherapy for

the treatment of various mental illnesses

(Leichsenring and Rabung 2008). When psychia-

trists use a ‘‘pill only approach’’ and rely entirely

on prescription medications to manage symptoms,

the social conditions (i.e., stressors) and lack of

coping resources that can influence symptoms of

mental illness may not be addressed. What are

the implications for civil liberties and physical

health if prescribed medications become the pri-

mary form of legally coerced psychiatric treat-

ment utilized?

There are differences between the civil and

criminal contexts regarding the level of coercionand possible benefits. Link and colleagues

(2011) argue that arrest is a severe form of coer-

cion based on breaking criminal laws, while assis-

ted outpatient treatment in the community, which

can involve mandated psychiatric medication, is

a gentler form of coercion. Their recent study

focused on New York State, where Kendra’s

Law implements court-ordered assisted outpatient

treatment (AOT) for people with mental illness,

not only based on whether they were dangerous

but also whether they had a history of multiplehospitalizations and treatment noncompliance.

Link and colleagues found that this type of AOT

significantly reduced the risk of subsequent arrest.

They concluded that AOT is a form of coercion

that can be administered to help prevent illegal

and dangerous events in the lives of people suffer-

ing from mental illness, which ultimately protects

society. A study by Swartz and colleagues (2010)

on AOT in New York State found additional pos-

itive outcomes, which included a significantly

reduced likelihood of psychiatric hospitalizationand improved receipt of psychotropic medica-

tions. There is also accumulating evidence that

legally coerced psychiatric medication and

outpatient commitment especially for serious

mental illnesses have other benefits, such as

improving social functioning and minimizing vio-

lence and suicide risk (Hiday 2003; Link et al.

2008, 2011; Phelan et al. 2010). Therefore, this

form of coercion in the civil context may have

long-term value. In the criminal context, it re-

mains controversial whether it is beneficial for in-

mates with diagnosed mental illnesses who are not

dangerous in prison to be coercively medicated to

render them competent to stand trial, such as for

the death penalty (e.g., the case of Russell

Weston who was diagnosed with schizophrenia,

had no awareness of his illness, and was noncom-

pliant with his medication regimen) (Torrey and

Zdanowicz 2001). Mental health courts, now

growing in number, focus on nonviolent defend-

ants suffering from mental illness, and avoidance

of incarceration or hospitalization is an incentive

for compliance with psychiatric treatment in the

community (Monahan et al. 2003). Overall, legal

coercion that involves avoidance of hospitaliza-

tion or incarceration is useful leverage for induc-

ing treatment adherence (Monahan et al. 2001).

Yet opponents caution that any form of involun-

tary psychiatric treatment limits civil liberties

(Allen and Smith 2001). Moreover, the treatment

should not only be prescribed psychiatric medica-tions but also other types, such as psychotherapy.

Psychiatric medications can be ineffective for

some patients and have harmful side effects.

They are certainly not a cure for mental illness.

At this point in time, we need to consider a critical

question regarding the treatment of people with

mental illness: To what extent do the social, psy-

chological, and physical costs of coerced psychiat-

ric medication outweigh the possible benefits for

the individual and society?

Finally, we would like to acknowledge severalstudy limitations. The GSS did not distinguish the

public’s attitudes about the coercion of different

kinds of psychiatric medications. Moreover, the

vignettes did not represent the wide range of men-

tal disorders in society, only a select few, which

are perhaps most familiar to the general public.

We were unable to make any causal inferences

about the public’s changing beliefs because the

GSS is cross-sectional and did not follow the

same individuals over time. Although we were

not able to assess individual-level changes in be-liefs, these national findings about changes in

aggregate-level beliefs are important because

they represent general public attitudes during









different decades. The GSS asked about legal

coercion but did not inquire about informal sanc-

tions to improve adherence to psychiatric medica-

tion. Additionally, the GSS did not directly assess

social-distancing behaviors. More research is nec-

essary to better capture stigmatizing behaviors and

experiences. The social distance items could also

be limited by social desirability. It is possible

that the respondents’ answers to the other vignette

questions may have been socially biased because

they may have believed that the goal of the survey

was to evaluate the public’s tolerance for people

with mental illness. The respondents also knew

that the GSS vignettes represented hypothetical

situations and their support for involuntary treat-

ment would not have had real consequences for

an individual. It also remains unclear whether

the public’s fear (about people with mental illness

likely being dangerous) is driving their ongoing

support for involuntary psychiatric medication

rather than the public’s knowledge of dangerous-

ness as the requirement for legal coercion.

Qualitative studies asking respondents to elabo-

rate on their answers rather than select from op-

tions could provide more valuable information

regarding Americans’ beliefs about mental illness

and civil liberties. Clearly, there are other reasons

why some Americans support the legal coercionof psychiatric medication that were not addressed

by the GSS, such as improving treatment compli-

ance and social functioning, which can help peo-

ple with mental illness avoid long-term

institutionalization in hospital or prison.

In conclusion, the majority of Americans do

not support the involuntary use of psychiatric

medication for the treatment of mental illness as

represented in the GSS vignettes. Although our

study suggests that stigmatizing preferences for

social distance may play less of a role in the pub-lic’s endorsement of the legal coercion of psychi-

atric medication, perceptions that persons with

mental illness are dangerous continue to be signif-

icant contributing factors. Negative attitudes of

the public about those with mental illness have

been seen as one of the biggest challenges in psy-

chiatric treatment. Therefore, it is imperative that

public policy makers continue to promote anti-

stigma initiatives through education, research,

and the media to prevent discrimination and

reduce barriers to medical treatment and counter-act the public’s lingering fear of people with men-

tal illness.

APPENDIX A

Vignettes

1. Alcohol Dependence

[John/Juan/Mary/

Maria] is a [white/African American/

Hispanic] [man/woman] with an

[eighth-grade/high school/college] edu-

cation. During the last month [John/

Juan/Mary/Maria] has started to drink

more than his/her usual amount of alco-

hol. In fact, he/she has noticed that he/

she needs to drink twice as much as

he/she used to to get the same effect.

Several times, he/she has tried to cut

down, or stop drinking, but he/she

can’t. Each time he/she has tried to cut

down, he/she became very agitated,

sweaty, and he/she couldn’t sleep, so

he/she took another drink. His/Her fam-

ily has complained that he/she is often

hungover and has become unreliable,

making plans one day, and canceling

them the next.

2. Major Depression [John/Juan/Mary/


Hispanic] [man/woman] with an

[eighth-grade/high school/college] edu-

cation. For the past two weeks [John/

Juan/Mary/Maria] has been feeling

really down. He/She wakes up in the

morning with a flat, heavy feeling that

sticks with him/her all day long. He/

She isn’t enjoying things the way he/

she normally would. In fact nothing

gives him/her pleasure. Even when

good things happen, they don’t seem to

make [John/Juan/Mary/Maria] happy.

He/She pushes on through his/her days,

but it is really hard. The smallest tasks

are difficult to accomplish. He/She finds

it hard to concentrate on anything. He/

She feels out of energy and out of steam.

And even though [John/Juan/Mary/

Maria] feels tired, when night comes

he/she can’t go to sleep. [John/Juan/

Mary/Maria] feels pretty worthless and

very discouraged. [John’s/Juan’s/

Mary’s/Maria’s] family has noticed

that he/she hasn’t been himself/herself for about the last month and that he/

she has pulled away from them. [John/









Juan/Mary/Maria] just doesn’t feel like

talking.

3. Schizophrenia [John/Juan/Mary/Maria]

is a [white/African American/Hispanic]

[man/woman] with an [eighth-grade/

high school/college] education. Up until

a year ago, life was pretty okay for

[John/Juan/Mary/Maria]. But then

things started to change. He/She thought

that people around him/her were making

disapproving comments and talking

behind his/her back. [John/Juan/Mary/

Maria] was convinced that people were

spying on him/her and that they could

hear what he/she was thinking. [John/

Juan/Mary/Maria] lost his/her drive to

participate in his/her usual work and

family activities and retreated to his/

her home, eventually spending most of

his/her day in his/her room. [John/

Juan/Mary/Maria] was hearing voices

even though no one else was around.

These voices told him/her what to do

and what to think. He/She has been liv-

ing this way for six months.

4. Drug Dependence [John/Juan/Mary/


Hispanic] [man/woman] with an[eighth-grade/high school/college] edu-

cation. A year ago [John/Juan/Mary/

Maria] sniffed cocaine for the first

time with friends at a party. During the

last few months he/she has been snort-

ing it in binges that last several days at

a time. He/She has lost weight and often

experiences chills when bingeing. [John/

Juan/Mary/Maria] has spent his/her

savings to buy cocaine. When [John’s/

Juan’s/Mary’s/Maria’s] friends try to

talk about the changes they see, he/she

becomes angry and storms out. Friends

and family have also noticed missing

possessions and suspect [John/Juan/

Mary/Maria] has stolen them. He/She

has tried to stop snorting cocaine, but

can’t. Each time he/she tries to stop

he/she feels very tired, depressed, and

unable to sleep. He/She lost his/her job

a month ago, after not showing up for

work.

5. No Mental Health Problem [John/

Juan/Mary/Maria] is a [white/African

American/Hispanic] [man/woman] with

an [eighth-grade/high school/college

education]. Up until a year ago, life

was pretty okay for [John/Juan/Mary/

Maria]. While nothing much was going

wrong in [John’s/Juan’s/Mary’s/

Maria’s] life, he/she sometimes feels

worried, a little sad, or has trouble sleep-

ing at night. [John/Juan/Mary/Maria]

feels that at times things bother him/

her more than they bother other people

and that when things go wrong, he/she

sometimes gets nervous or annoyed.Otherwise [John/Juan/Mary/Maria] is

getting along pretty well. He/She enjoys

being with other people, and although

[John/Juan/Mary/Maria] sometimes ar-

gues with his/her family, [John/Juan/

Mary/Maria] has been getting along

pretty well with his/her family.









APPENDIX BOdds Ratios from Logistic Regression of Endorsement of Involuntary Psychiatric

Medication: Trends from 1996 and 2006 General Social Survey Mental Health

Modules

Variables Model 1 Model 2 Model 3 Model 4

Survey year (1 = 2006, 0 = 1996) 0.908 0.967 1.363 2.142Vignette characteristics

Female 0.768*

Female 3 Year 1.039Non-Hispanic white 1.022Non-Hispanic White 3 Year 1.093College 0.935College 3 Year 1.168

Depressiona 0.885Depression 3 Year 2.866***

Schizophreniaa 2.466***

Schizophrenia 3 Year 2.726***

Alcohol dependencea 1.031Alcohol Dependence 3 Year 1.704Drug dependence — Drug Dependence 3 Year —

Causes of mental illnessBad character 1.277**

Bad character 3 Year 0.944Chemical imbalance 1.237*

Chemical Imbalance 3 Year 1.061Way raised 0.935Way Raised 3 Year 0.885Stress 1.050Stress 3 Year 0.836Genetics 1.049Genetics 3 Year 1.147God’s will 0.911God’s Will 3 Year 1.237

Perceived dangerousnessViolent to self 1.621***

Violent to Self 3 Year 0.808Violent to others 1.402**

Violent to Others 3 Year 1.141Stigma

Preferences for social distance 1.528***

Preferences for SocialDistance 3 Year

0.733*

Notes: All models adjust for respondents’ age, race/ethnicity, gender, education, employment, religious attendance,Southern residence, and rural residence.a.The reference category is ‘‘no mental health problem.’’*p \ .05. **p \ .01. ***p \ .001.









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