Public attitudes towards psychiatric medication: a comparison between United States and Germany

Psychiatric medication (PM) is becoming more and more popular, which is reflected in rising prescription rates in most Western countries. However, absolute prescription rates differ between countries (1), and there also seem to be country differences in public attitudes towards PM (2–4). Representative population surveys suggest that PM is particularly popular in the U.S., but it is unclear whether this is a true difference or merely the result of different questionnaire wording or survey methodology.

Knowing whether public attitudes in the U.S. differ from other countries would be of particular interest, because only in the U.S. (and New Zealand) direct to consumer advertising (DTCA) of prescription drugs is legal. DTCA may be associated with more positive views on PM among the general public. The effect of DTCA on consumer attitudes and behavior has been discussed critically (5), but a direct cross-country comparison of public attitudes towards medication is lacking. Here we report the results of a study comparing public attitudes towards PM in the U.S. and Germany, using data from the U.S. General Social Survey (GSS) 2006 and from a population survey conducted in Germany in 2011.

Two population-based random samples in the U.S. (N= 1,437) and in Germany (N=1,223) received identical questions on PM during a fully structured face-to-face interview (see 4,6 for details on sampling and interview methodology). The questions on attitudes towards PM were first used in the GSS (6). For the German survey, items were translated according to World Health Organization guidelines (7). Six statements assessed views on harms and benefits of PM, and four enquired whether the respondent would take doctor-prescribed PM in various situations, ranging from personal trouble to acute depression or anxiety.

Responses were recorded on five-point Likert scales, which we combined into three categories for our analyses: agree or likely, undecided, unlikely or disagree. A fourth category was “don't know”. We then calculated multinomial logit regression models for all items, comparing the predicted probability for choosing each category between countries. Analyses controlled for respondents' gender, age, and years of education, holding all control variables at their mean for the combined sample. We computed 95% confidence intervals (CI) for the predicted country difference with the delta method to establish significance. We multiplied probabilities by 100, so they can be read as percentages. We report country differences in agreement, which were all significant (p<0.05).

In the U.S., perceptions of potential harm of PM were much lower than in Germany. The statement that PM is harmful to the body was endorsed by 58% of respondents in Germany versus 27% in the U.S. (predicted difference: −31%). In Germany, 72% agreed that taking these medications interferes with daily activities, versus 44% in the U.S. (predicted difference: −28%).

More people in the U.S. expected benefits from PM. The statement “taking these medications helps with day-to-day stresses” was endorsed by 81% in the U.S. versus 75% in Germany (predicted difference: 6%). In the U.S., 75% of respondents expected that PM makes things easier in relations with family and friends, versus 65% in Germany (predicted difference: 9%). Expectation that medication helps people control their symptoms was only slightly higher in the U.S. (84 vs. 80%), and slightly less respondents in the U.S. endorsed that PM helps people feeling better about themselves (65% vs. 71%).

Respondents in the U.S. were considerably more likely to take PM: 63% in the U.S. would take medication for symptoms of anxiety, versus 48% in Germany (predicted difference: 15%); 49% in the U.S. considered themselves likely to take medication for symptoms of depression, versus 26% in Germany (predicted difference: 23%). Similar country differences were also present in situations where taking medication is not indicated: 47% in the U.S. (versus 30% in Germany) would take PM if they didn't know anymore how to cope with the stresses of life; 30% in the U.S. (versus 14% in Germany) would take PM because of trouble in their personal life.

In summary, public attitudes towards PM are considerably more favorable in the U.S. than in Germany. It is to be acknowledged that the surveys in the U.S. (2006) and Germany (2011) were conducted in different years. However, assuming the overall trend towards more positive medication attitudes (6) had continued in the U.S. after 2006, attitudes of the U.S. participants would have been even more positive in 2011.

The U.S. and Germany differ with regard to a number of social, cultural and health care system factors, of which DTCA is only one. Also, it is worth considering that more permissive population attitudes towards medication could also have paved the way towards legalizing DTCA.

Since the FDA issued new guidelines facilitating DTCA of prescription drugs in 1997, many studies have examined potential negative consequences of this development (for a review, see 5). Although increases in antidepressant use have been reported in many countries, it has been shown that exposure to DTCA in television and print media was associated with an additional 3–10% increase in antidepressant consumption rates (8). DTCA may increase AD consumption not only for clinically relevant depression or anxiety disorder, but also for other, sub-threshold conditions where antidepressant medication use may not be indicated and where taking drugs would do more harm than good (5,9). In our study, willingness to take PM was greater in the U.S. than in Germany for all hypothetical situations, regardless of whether it was medically appropriate. Although the greatest difference was observed in depression, twice as many respondents in the U.S. than in Germany were also willing to take medication when dealing with personal trouble.

The largest between-country differences were with regard to perceived harms of PM. A potential reduction of harm awareness as a result of DTCA would be of particular concern. The two psychiatric drugs that were advertised most between 2007 and 2011 already have black box warnings for serious side effects (duloxetine: suicidality in young people; aripiprazole: mortality in dementia patients, and suicidality) (5). Several drugs outside the field of psychiatry that were promoted through DTCA in the U.S. were later withdrawn due to severe side effects, e.g. COX-2 inhibitor rofecoxib in 2004. Benefits of PM might thus be outweighed by the harm due to increased rates of side effects in persons that would not have needed medication (10).

In conclusion, our study found significant differences in public attitudes towards PM between the U.S. and Germany. People in the U.S. were more willing to take psychiatric medications, even in situations where they are not indicated, less concerned about the possible harms, and more strongly convinced of the benefits of these medications. These differences may reflect, at least in part, the effects of DTCA, but also point towards other cultural, social and health care system differences between the two countries.