Discussion
This is the first study to investigate public attitudes and perceptions of treatment recommendations for depression and schizophrenia in Vietnam. Understanding treatment recommendations, as well as response behavior in the context of its sociocultural environment could lead to a deeper understanding of public awareness and causal beliefs of mental health disorders and perceived demands for mental health care provision. Numerous studies highlighted the influence of people’s help-seeking behavior [
26,
43] and associated stigma [
44] on the course of mental illness.
Remarkably, for both disorders, the same top five recommendations for healthcare providers (psychiatrist, psychotherapist, general practitioner, a person of trust, and rehabilitation facility) received predominately positive recommendations. Moreover, the same five options (internet, natural health healer, priest, Feng Shui master, contact ancestor via a medium) were overall marginally recommended for both conditions. Psychiatrists were among the four most preferred choices for both disorders which are in line with recent research constituting public trust and preferences towards psychiatrists in Vietnam [
27]. Interestingly, in Vietnam, the most favored healthcare provider, psychotherapists, received equally high recommendation rates compared to a recent meta-analysis in different Western as well as Eastern societies [
37] which reported that 76% recommended psychotherapy for depression and 85% for schizophrenia. This advanced public understanding of adequate psychiatric-psychological treatment, however stands in contrast to the lack of mental health care facilities and integrated psychotherapeutic options in Vietnam. Despite pilot efforts of a study programme of clinical psychology and psychotherapy [
45,
46], there is a need for a structured psychotherapy curriculum in Vietnam. This need becomes especially evident when considering that psychotherapy receives the highest recommendation rates of 92% for schizophrenia and 79.4% for depression. However, national guidelines for health insurance have not yet defined psychotherapy, and therefore, health insurances do not cover its cost [
47]. Henceforth, the image of a psychotherapist as a person of reference, trust as well as openness and nurturing care and mindful listener seems anchored in society even though its availability and accessibility are lacking [
37]. In a next step, an emic public understanding of what psychotherapy defines may be studied with qualitative methods.
Meanwhile, the absence of sensitive sociocultural research on psychotherapeutic interventions in Vietnam remains challenging [
14,
15], even though the results indicate that the Vietnamese public primarily endorse professional help. Within the psychiatric outpatient clinic specialized on Vietnamese migrants in Germany at the Charité-Universitätsmedizin further enhanced approaches of informed cultural psychotherapy for Vietnamese patients are in development. Considering the focus on the socio-cultural dimensions of emotion, affect and relationality, such group therapy options show promising results and may be implemented in future studies in Vietnam [
31]. Nevertheless, the fact that the four most recommended providers for both vignettes, such as psychiatrist, psychotherapist, a person of trust and a general practitioner, are well-validated interventions in the mental health care system [
48‐
50], suggests a public understanding concerning the complex nature of both mental disorders, schizophrenia and depression. It further indicates an informed mental health literacy of Vietnamese respondents in our sample, manifested in a general trust in a medical approach and psychiatric treatment options, despite its ubiquitous and challenging treatment gap. Additionally, in the context of Vietnam where specialist resources are scare, an approach to tackle the lack of adequate mental health care might be to train general practitioner with basic psychiatric and psychotherapeutic knowledge as a short-time approach while reinforcing the personal resources of the mental health system in the long term.
Even though the public’s recommendation hierarchies are overall similar for both conditions regarding treatment providers, medical professionals, such as psychiatrists, psychotherapists and general practitioners were more strongly endorsed for schizophrenia, while interpersonal-based treatments by a psychotherapist or a person of trust received the highest endorsement for depression. This difference in preferences for treatment options and professional health care providers for both conditions illustrates a public perception that schizophrenia is seen predominantly as a medical and thus biological disorder. In various studies, schizophrenia was perceived as the more severe mental disorder [
51‐
53] followed by alcohol abuse, anxiety disorders and lastly depression, a perceived hierarchy that persists also in the Vietnamese context [
22]. Contrasting to schizophrenia, causes of depression, especially in the Asian cultural sphere, were perceived as being rooted in psychosocial or interpersonal related stressors rather than in biochemical dysbalances, [
22,
54‐
56], thus interpersonal treatment providers were more often favoured. These differences between causal beliefs about schizophrenia and depression could also account for the substantial difference in recommendation between schizophrenia and depression for psychiatrists in Vietnam. Moreover, psychiatrists who are licensed to prescribe psychotropic medication might receive attribution of higher competence in dealing with schizophrenia, perceived as a biological illness, rather than a psychological misbalance of mood as in depression [
57].
At the same time, self-help strategies and person of trust were recommended more frequently for the depression than for the schizophrenia vignette. Chen and colleagues [
54] reported that 75% of Asian American participants with depression endorsed self-management as favorable over pharmacological interventions. The authors also embedded the findings in the understanding of the etiology of depression as being of psychosocial rather than biochemical origin [
54]. Furthermore, it was found that relationship-based stressors, such as romantic love or partnership conflicts, were endorsed more frequently as causes of depression in Asian Americans [
54,
58,
59], which in the public perception may demand personal advice from a person of trust. A more frequent recommendation of self-help might additionally reflect the perceived value of self-efficacy in the case of depression in contrast to schizophrenia. Endorsing self-efficacy our results showed significantly more respondents, who recommended help-seeking in internet in case of depression in comparison to the schizophrenia vignette condition.
Traditional Vietnamese Medicine (TVM) is deeply rooted in the Vietnamese health system and has nowadays become a part of the formal health care system [
60]. In Vietnam, approximately 30% of all patients receive treatment with traditional medicines [
60]. Especially in the health prevention and treatment of chronical disease conditions, such as stomach and intestinal disease, Gout or musculoskeletal conditions such as a chronic backache or arthritis TVM plays an important role [
61]. However, the same study assessed that only 2.1% of participants used complementary and alternative medicine for the treatment of mental disorders [
61]. However, Vietnamese patients with a major depression frequently reported pain or dizziness and patients with “Phong thấp” or “neurasthenia” in the Vietnamese context frequently displayed depressive symptoms [
62]. It could be hypothesized, that a part of the patients with chronical illness conditions also has a mental disorder and still used TVM. Interestingly, in our sample, except meditation or Yoga, traditional medicine treatment options such as natural medicine, acupuncture and natural healers were mostly considered unfavourable. A possible explanation is that we used a vignette for depression that did not feature any somatic symptoms. Therefore, the respondents did not associate the case and the use of TVM. The fact that natural healers and treatment measures such as Feng Shui and praying received more endorsement for schizophrenia might be attributed to a state of helplessness in the face of the perceived severity of the disease. Others might turn to supernatural powers or have hope in miracle healings contributing to patient improvement [
63] and ultimately inducing a feeling of being in control [
64]. Furthermore, schizophrenia symptoms such as thought control, hallucinations, and delusions of reference are more often related to spiritual terms such as possessions and bewitchment [
65] rather than interpersonal symptom expressions as in the depression vignette. Thus, in line with symptom perception and causal explanations, spiritual associated treatment facilitators might be more recommended in cases of schizophrenia. In contrast, the effectiveness of traditional therapy options in depression and stress-associated disorders is often higher in comparison to patients affected by psychosis [
66]. Moreover, traditional healers who suggest a medication-free approach may influence the course of psychosis by increasing the risk of relapses [
67]. However, traditional healthcare providers could also facilitate mental health care utilization in some cultures, if they act as an additional treatment option within the mental health system [
68]. Another perspective might be that the utilization of traditional approaches represents a shortage or high barrier of adequate treatment option rather than distrust into medical psychiatry itself [
61,
68].
Even though recommendations and dissuasion rates are similarly distributed across both conditions regarding treatment measures, significant differences on individual levels of treatment options are observable. On the one hand, endorsements for ECT display higher levels of dissuasion for both disorders, which may be related to public perceptions of ECT as a drastic measure, due to ECTs historic role in psychiatry and enduring misrepresentation in popular media [
69,
70]. On the other hand, even though ECT is one of the five least recommend interventions, there is a significant difference between both vignettes. Over 27% of respondents endorsed ECT for schizophrenia while only around 19% by depression. One reason might be the discussed perception of schizophrenia as a more severe mental illness based on biological defects rather than a psychological imbalance of mood [
22,
36,
71,
72].
Vietnamese respondents for both vignettes endorsed overall high levels of recommendations for low-threshold interventions, such as relaxation or concentration training, as well as meditation or yoga, which may be perceived as less harmful and non-intrusive. Yoga and meditation are the two measures which are nearly equally frequently recommended for schizophrenia and depression. These results for both conditions stand partially in contrast to findings from Western countries were low-threshold interventions such as meditation, yoga, and acupuncture were declined while relaxation was recommended [
73]. This discussion is weighed in the light of Vietnam’s cultural context, which is influenced by Buddhist traditions and folk religions [
74]. Concentration and relaxation exercises such as mindfulness, meditation, and yoga are deeply rooted in Buddhist shaped societies and have a long enduring tradition in facilitating mental well-being [
75,
76].
The current study must be interpreted in the light of several limitations which should be addressed in future research. First, the study was conducted in the rural and urban areas of Hanoi, the capital city of Vietnam leading to results, which cannot be generalized for the whole country, acknowledging its social and cultural diversity. Second, overall higher educational levels of participants from Hanoi compared to of the population in Vietnam (77.8% with upper secondary school vs. 66.7%) could explain a potentially higher mental health literacy. Third, the collected data was assessed cross-sectionally, limiting any causal explanatory power of the study. Finally, a list of a priori determined answer possibilities might account for bias, as this approach may render further answer options unfeasible. However, sociocultural sensitive treatment facilitators such as acupuncture, seeking Feng Shui master or contact ancestor via medium were considered. Nevertheless, qualitative approaches might give insight into new explanatory patterns, respondents understanding of terms and answer possibilities.
Authors’ contributions
The secondary data compilation, data analysis and collection, and interpretation were done by KB and TMTT. The EH, TDC and TMTT contribute to study design and collecting of sample. The EH, TDC, LMF and LKM revised the manuscript thoroughly with their individual expertise. In the analysis of data, all authors played a significant part as well as in designing and preparing the manuscript. Proofreading and the final approval process was also shared accordingly among all authors and all authors have agreed to its submission for publication. All authors read and approved the final manuscript.