Public Attitudes and Feelings of Warmth Toward Women and Men Experiencing Depression During the Perinatal Period
Abstract
Objective:
Depression is a major public health concern and often goes untreated. In response to a growing body of research documenting stigma as a barrier to depression care, this study focused on examining public stigma toward potentially vulnerable subpopulations.
Methods:
Participants (N=241) were recruited from Amazon’s Mechanical Turk and randomly assigned to provide anonymous ratings on attitudes and feelings of warmth toward pregnant women and expectant fathers experiencing depression, mothers and fathers experiencing postpartum depression, or women and men experiencing depression during nonperinatal periods.
Results:
Participants reported significantly more negative attitudes about depressed men than women, and male participants reported significantly more negative attitudes than female participants toward depressed individuals. Similarly, participants felt significantly less warmth toward depressed men than women, and male participants expressed significantly less warmth than female participants toward depressed individuals. Male participants felt equally warm toward men and women who experienced depression during nonperinatal periods, whereas female participants felt significantly warmer toward women who experienced depression during nonperinatal periods compared with men.
Conclusions:
Results indicate that the public views depressed men more negatively than depressed women and that males are more likely to hold stigmatizing attitudes toward depression, suggesting the importance of reducing stigma directed toward men with depression and stigma held by men toward persons with depression. Attitudes and feelings toward depressed individuals did not consistently vary by perinatal status. These findings are an initial step in improving depression treatment engagement strategies and in identifying those who would benefit most from stigma reduction programs.
Depression is a major public health problem and is estimated to be the second leading cause of disability globally (1). Despite the availability of effective treatments, the majority of individuals with depression are untreated or undertreated (2). Moreover, certain subpopulations of persons with depression have even lower rates of treatment engagement than the general population. Depression frequently goes undetected and untreated among pregnant women (3,4), and rates for help seeking among depressed men are low (5,6). Although public stigma toward depression is cited as a barrier to care, research has primarily focused on perceptions of depression generally rather than on perceptions of depression in vulnerable populations. The purpose of this study was to examine public perceptions of depression in these vulnerable populations and identify individuals who may be more likely to stigmatize depressed individuals. These are important steps in expanding knowledge of potentially modifiable factors that may increase access to depression care.
We focused on public attitudes toward depression during the perinatal period (pregnancy and postpartum) for two reasons. First, nearly 20% of women experience depression during pregnancy or in the first three months postpartum (7). Also, perinatal depression is not exclusively a “women’s problem”; approximately 10% of men experience depression during the perinatal period (8,9). Depression during this life cycle phase is associated with adverse outcomes for parents and children (10–13). Second, pregnant women and women who have recently given birth report that perceived stigma is a barrier to depression care (4,7,14–20). There is a dearth of research examining rates of help seeking and perceptions of stigma among men who experience depression during the perinatal period; however, societal norms about masculinity—invulnerability, independence, and low emotionality—may be obstacles to seeking help for depression (21–23). Of potential relevance for the perinatal period, men are less likely to report depression when depression is described as the result of uncontrollable factors, such as life experiences, versus controllable factors, such as a negative attitude (22).
Research on public attitudes about depression has yielded mixed results; some research indicates that people express supportive, nonstigmatizing attitudes toward persons with depression, as well as pity, sympathy, and a desire to help (24,25). Other research highlights negative public attitudes toward depression, such as believing depressed individuals are unpredictable or dangerous (24,26). Gender stereotype research suggests that women are viewed more favorably than men, labeled the “women-are-wonderful effect,” and that attitudes toward mothers are particularly positive relative to other groups of women (27). Because mothers are held in such high esteem, women who experience depression during the perinatal period may be viewed less negatively than depressed women generally or than men who experience depression during the perinatal period. In contrast, when behaving in gender- or role-incongruent ways—for example, applying for a job—pregnant women are subject to more negative attitudes compared with nonpregnant women engaging in the same behaviors (28). Thus women who experience depression during the perinatal period may violate cultural expectations of a “good mother” and be viewed more negatively than depressed women generally or men who experience depression during the perinatal period.
This study aimed to elucidate the extent to which attitudes about and feelings of warmth toward depressed individuals depend on whether the depressed individual is male or female and whether the individual experiences depression during pregnancy, the postpartum period, or neither period. Additionally, in an effort to identify characteristics of individuals who may be more likely to stigmatize depression, we examined whether responses differed between male and female participants. Research suggests that men hold more stigmatizing attitudes about depression than women (26,29) and that men demonstrate less in-group gender bias (preference for a group in which one is a member) than do women (30).
The goals of this study were to expand understanding of the extent and nature of public stigma toward depression specifically among women and men during the perinatal period. Such understanding may inform the development of more effective treatment engagement strategies and identify individuals who would most benefit from stigma reduction interventions. Participants were randomly assigned to report attitudes about and feelings of warmth toward depressed pregnant women and expectant fathers, men and women experiencing depression during the postpartum period, or depressed women and men. We examined the extent to which depression stigma depended on target gender, target perinatal status, and their interaction. Additionally, we predicted that male participants would be more likely to express stigmatizing attitudes generally and examined interactions between participant gender, target gender, and target perinatal status.
Methods
Participants
The institutional review board at the University of Colorado Boulder approved the study protocol. In August 2013, participants were recruited through Amazon’s Mechanical Turk (MTurk) marketplace, and paid $.50, typical of what workers were paid on MTurk at the time of data collection. MTurk has been used to assess public stigma related to depression (31) and shown to be a useful strategy to collect high-quality data rapidly (32,33). Although MTurk is not perfectly representative of the United States population, it has been shown to be more representative than other convenience samples, such as undergraduate students and other Internet samples (32–34).
Measures and Procedures
After reading a brief description of the study, participants completed the consent form and measures on Qualtrics, a password-protected, secure survey site. Participants were randomly assigned to provide responses about one of the following three sets of targets: depressed pregnant women and expectant fathers (N=85), men and women experiencing depression during the postpartum period (N=75), and depressed women and men (N=81).
Sociodemographic characteristics.
Participants completed a study-designed measure of sociodemographic characteristics, including gender, race-ethnicity, relationship status, education, age, parental status, personal experience with depression, and political orientation. Personal experience with depression was assessed by asking participants to indicate whether they had ever experienced depression generally, during pregnancy or the postpartum period (for women), or during a spouse’s or partner’s pregnancy or postpartum period (for men). A categorical variable was calculated such that participants who endorsed any of the personal experience with depression items were coded as having personal experience with depression. Participants were asked to describe their political orientation on a Likert scale from 1, extremely liberal, to 7, extremely conservative. No other identifying information was collected.
Attitudes about perinatal depression.
Eighteen items were generated for the Attitudes and Beliefs About Perinatal Depression Questionnaire on the basis of a review of qualitative literature about perceived depression stigma among pregnant women and mothers in the postpartum period (14–17), a review of mental illness and depression stigma measures (29,35–37), and theoretical models of public stigma (38) (Table 1). The questionnaire was developed to examine attitudes about depression occurring during the transition to parenthood, particularly about depression’s effects on fitness to parent (items 1, 3, 7, 8, and 9). Qualitative literature of perceived depression stigma among women who are pregnant or who have recently given birth elucidated several perceptions unique to this life cycle phase, such as concerns that others view them as a danger to the child, as incapable of caring for a child, or as being a bad parent.
| Item # | Item |
|---|---|
| 1 | Depressed pregnant women should temporarily give up care of their babies to someone else |
| 2 | Depressed pregnant women are a danger to themselves |
| 3 | Depressed pregnant women are a danger to their babies |
| 4 | Depression in pregnant women is a sign of moral weakness |
| 5 | Depressed pregnant women should probably keep their depression to themselves |
| 6 | It is easy to notice the symptoms of depression among pregnant women |
| 7 | Depressed pregnant women probably aren't capable of taking care of children |
| 8 | Knowing that a pregnant woman is depressed tells me a lot about what kind of parent she would be |
| 9 | Depressed pregnant women are bad mothers |
| 10 | Depressed pregnant women are personally responsible for their depression |
| 11 | Pregnant women have only themselves to blame if they struggle with depression |
| 12 | Depressed pregnant women should do their best to keep their symptoms hidden |
| 13 | There is little that can be done to control the symptoms of depression in pregnant women |
| 14 | A person can tell that pregnant women are depressed by the way they act |
| 15 | Depression in pregnant women can be treated successfullyb |
| 16 | Depression in pregnant women is a common problem in our societyb |
| 17 | It is common for pregnant women to suffer from depressionb |
TABLE 1. Attitudes and Beliefs About Perinatal Depression Questionnairea
This questionnaire was developed by an advanced clinical psychology graduate student and a licensed clinical psychologist, both with expertise in treatment of depression, and an advanced social psychology graduate student and a professor of social psychology, both with expertise in psychometrics and scale development. Item inclusion was decided primarily based on the face validity of the items. Participants were asked to complete a Likert scale indicating the extent to which they agreed with statements about each randomly assigned target group, with 1 indicating strong disagreement and 7 indicating strong agreement. Items were presented in a random order for each target group. Three items were worded such that greater agreement indicated more positive attitudes toward the target group; these items were reverse-scored. Item-total correlations in the current sample suggested that one item had a low correlation with the remaining items (item-total correlation of ≤.07 for each target group), and Cronbach’s alpha was decreased by the inclusion of this item. This item was dropped, resulting in 17 items, averaged to create an aggregate attitude score toward each target group, with higher mean scores indicating more negative attitudes. Cronbach’s alpha was at least .80 for each target group for the 17-item version of the questionnaire, indicating good internal consistency.
Ratings of warmth.
Participants completed a “feeling thermometer,” widely used to assess general liking for various target groups (39). Participants were instructed to drag a slider from 0 to 100 to indicate how coolly (0) or warmly (100) they felt about each randomly assigned target group.
Data Analysis
Of 256 participants who completed the study, 15 were excluded from analyses after failing two or more attention checks, resulting in a total sample of 241 participants. All data analyses were performed by using SPSS, version 23. Public attitudes and feelings of warmth were examined separately as a function of target gender, participant gender, and target perinatal status. Thus the design of the study was a 2 (target gender [male or female] within participants) × 3 (target perinatal status [pregnant, postpartum, or neither] between participants) × 2 (participant gender [male or female] between participants) mixed analysis of variance (ANOVA). Orthogonal contrast codes were used to capture differences in survey results by target perinatal status. To compare results for the three perinatal groups, one code compared results for perinatal targets (both pregnant and postpartum) and nonperinatal targets, and the second orthogonal code compared results for pregnant and postpartum targets (40).
Results
Participant Characteristics
The majority of the 241 participants were female (N=135, 56%), white (N=191, 79%), and not currently married (N=150, 62%). Less than half had completed college (N=101, 42%). Median age was 33.00 years (mean±SD=36.95±13.78). About half of participants were parents (N=114, 47%) and had personal experience with depression (N=123, 51%). On average, political orientation was reported as slightly more liberal than conservative (mean score=3.25±1.57). There were no significant differences in any of these variables as a function of the targets that participants were assigned to evaluate.
Attitudes About Perinatal Depression
Aligning with the “women-are-wonderful effect” (27), a main effect of target gender indicated that participants had significantly more negative attitudes about depressed men than about depressed women (mean scores of 2.80±.79 and 2.68±.78, respectively; F=16.91, df=1 and 235, p<.001). Moreover, male participants had significantly more negative attitudes than female participants toward depressed individuals (3.00±.78 and 2.54±.65, respectively; F=25.34, df=1 and 235, p<.001). No other main or interaction effects were significant.
Warmth Ratings
Consistent with results for attitudes, participants felt significantly less warm toward depressed male targets compared with depressed female targets (63.02±24.63 and 71.46±22.69, respectively; F=42.80, df=1 and 235, p<.001), and male participants felt significantly less warm than female participants toward depressed targets (61.88±20.13 and 71.45±21.67, respectively, F=11.97, df=1 and 235, p=.001). However, a three-way interaction indicated that ratings depended on target gender, participant gender, and perinatal status (F=6.68, df=1 and 235, p=.01). Breaking down the three-way interaction by perinatal status revealed that the two-way participant gender × target gender interaction was significant for nonperinatal targets (F=8.53, df=1 and 235, p=.004) but not for perinatal targets. Simple effects for nonperinatal targets showed that male participants felt equally warm toward the male and female targets who were depressed during the nonperinatal period (60.31±18.04 and 60.51±20.73, respectively) but that female participants felt significantly warmer toward depressed female nonperinatal targets compared with depressed male nonperinatal targets (74.76±22.17 and 61.81±23.08, respectively; F=18.29, df=1 and 235, p<.001). For perinatal targets, there was a significant main effect for target gender, such that participants felt warmer toward female compared with male targets (73.27±22.63 and 64.00±26.41, respectively; F=35.40, df=1 and 237, p<.001). In sum, all participants felt generally warmer toward female than male targets, women felt generally warmer than men toward all targets, and men felt equally warm toward male and female targets who were depressed in the nonperinatal period.
Discussion
This study was designed as an initial step in examining public attitudes about depression that occurs during the transition to parenthood. The central story to emerge from this work was that men were more likely both to be stigmatized and to stigmatize. Moreover, our results suggest that the public may not hold more negative attitudes or colder feelings toward individuals who experience depression during the perinatal period than toward individuals who experience depression at other times of life.
Participants reported significantly more positive attitudes and greater warmth for depressed women than depressed men. The results converge with prior work suggesting that in general women are viewed more favorably than men (28,41) and represent a novel extension of this work to depressed individuals. The findings likely reflect the extent to which traditional norms about masculinity—for example, invulnerability, independence, and low emotionality—conflict with beliefs about individuals with depression—for example, that they are weak, pitiable, or emotional. As a result, depressed men may be judged harshly for violating traditional gender norms of strength and invulnerability. These findings have clinical and public health relevance given emerging research indicating that many men experience depression during the transition to parenthood.
Future research should examine whether more negative attitudes and colder feelings toward depressed men are due to perceived low prevalence rates for depression among men. To the extent that the general public views depression among fathers as rare or unusual, and particularly if such views influence attitudes and feelings of warmth, it is possible that education and outreach programs that emphasize that men also experience perinatal depression can lessen the stigma surrounding perinatal depression among men. Our research adds to the growing body of evidence documenting associations between adherence to traditional masculine norms and low rates of help seeking for depression among men generally (42). More research is urgently needed to develop treatment engagement and intervention programs sensitive to the role of stigma as a barrier.
Our findings that men had more negative attitudes toward depressed individuals than women are consistent with prior research (26,29) and highlight potentially important priorities for stigma-reduction interventions. Men may benefit most from targeted mental health stigma–reduction programs, and a recent review points to the efficacy of such programs (43). Such interventions frequently involve providing general education or increasing social contact with individuals with mental illness. Psychoeducation interventions to reduce self-stigma among individuals with mental illness also show promise (43).
The second key finding was that, on the whole, people did not hold more negative attitudes or colder feelings toward individuals who experienced perinatal depression than toward individuals who experienced nonperinatal depression. The results and limitations of this study raised many important questions. Future research on attitudes about perinatal depression may benefit from focusing on persons who influence decisions to seek help for depression, such as friends, family, and health care providers. Research suggests that 83% of women with elevated depression symptom severity during the perinatal period reported consulting with friends and family members about their symptoms (44). Stigmatizing attitudes and negative emotions among friends and family, as compared with the general public, may have a greater impact on women’s decisions about treatment. Although research on depression stigma generally has found that health care providers expressed the least amount of stigma compared with other participants (29), research on depression stigma toward pregnant women specifically found that medical, pharmacy, and nursing students expressed at least some stigma toward depressed pregnant women and that nursing students were the most likely to report feelings of stigma (45).
Although our goal was to obtain an index of attitudes in the general public about perinatal depression, our use of an MTurk sample had limitations; for example, 79% of participants in our sample were white. It is important for future work to address limits to generalizability by indexing attitudes about perinatal depression in nationally representative samples.
Our findings also should be considered in the context of our measurement methods. Given the lack of existing measures of stigma toward parents with depression, our attitudes measure was based on qualitative literature and on existing mental illness and depression stigma measures. It was not subject to independent expert review or pilot testing prior to use. Although we obtained good internal consistency in the current sample (α=.80), further psychometric analysis is needed to determine the validity of this measure, including measuring congruent validity with other stigma measures (46). It would be useful to the field to develop a standard measure for assessing stigmatizing attitudes about general medical and mental health problems in order to facilitate comparisons across targets and samples.
It is possible that participants did not report negative attitudes about the target groups because of social desirability or lack of awareness of biases (47). Although the anonymity of this study may have reduced demand characteristics, the use of implicit measures, which are less vulnerable to bias than traditional self-report methods, may improve understanding of negative attitudes toward depression (48). Research suggests that there are important dissociations between implicit and explicit measures of mental illness bias (49–51); for example, implicit, but not explicit, biases among mental health providers are associated with recommending more controlling, restrictive, and nonautonomous interventions (51). Future work is needed to examine dissociations between implicit and explicit depression biases and their unique or common behavioral correlates.
Negative attitudes among the public about depression during the perinatal period may be communicated in other ways than those assessed in this study, such as through popular media. Future research should utilize content analysis strategies (52) to examine the type of messages that are conveyed by the media about women and men who experience depression during the perinatal period, including social media (25), news outlets, magazines, popular blogs, and pregnancy and parenting literature.
Finally, our study did not speak to how the attitudes of others affect how men and women with perinatal depression view themselves. To what extent do women and men who develop depression during the perinatal period internalize negative or stigmatizing messages, and at what cost? Negative maternal attitudes, including expectations of judgment and idealization of the maternal role, are significantly associated with higher depression symptoms among perinatal women (53,54). Because motherhood is idealized (55,56), perinatal women may feel particularly ashamed for experiencing depression. Self-stigma is important among men; men’s higher endorsement of masculine norms and worse attitudes toward help seeking are mediated by self-stigma (57). Future research should examine the impact of self-stigma on help seeking for perinatal depression.
Conclusions
This research represents an important first step in examining public attitudes toward perinatal depression and indicates that individuals who experience depression during the perinatal period were not viewed more harshly than depressed individuals generally. Our results indicate that depressed men were viewed more negatively than depressed women. Taken together with research demonstrating the effects of masculinity norms on rates of help seeking for depression, our findings have important public health and clinical research implications. Further work is needed to determine how best to change public perceptions of men with depression as well as to develop treatment engagement strategies that overcome stigma as a barrier to help seeking. Additionally, men reported more negative attitudes and cooler feelings toward individuals with depression compared with women. Thus it may be helpful for depression stigma reduction programs to focus, at least in part, on men. Future research using alternate measurement methods is needed, including a focus on how attitudes affect behavior, for example, discrimination.
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