Knowledge of and attitudes toward epilepsy surgery among neurologists in Saudi Arabia

Objectives:To investigate the levels of knowledge and attitudes toward epilepsy surgery among neurologists in Saudi Arabia and evaluate the factors that affect the physicians’ knowledge and attitudes.Methods:A quantitative observational cross-sectional study conducted at King Saud University Medical City, Riyadh. The data were collected using a newly developed, self-administered online questionnaire. The questionnaire contained 3 sections: demographic information, knowledge, and attitudes which then sent to neurologist in Saudi Arabia from December 2016 to March 2017.Results:A total of 106 neurologists met our inclusion criteria. Eighty percent of the participants had at least one epilepsy center in their city, and 78% indicated that they had access to adequate expertise and resources to enable the appropriate selection of epilepsy surgical candidates. Only 57.5% of the neurologists had a sufficient level of knowledge regarding epilepsy surgery. Neurologists with higher level of knowledge referred more patients to EMU and discussed epilepsy surgery more often with their patients. Overall, more than half of the neurologists (52.8%) had a positive attitude toward epilepsy surgery. There was a significantly positive correlation between the scores of knowledge and attitude (p<0.001).Conclusion:Neurologists in Saudi Arabia appear to have moderate knowledge of and positive attitudes toward epilepsy surgery. The place of the last neurology certificate, type of practicing hospital, and access to expertise and resources, affected their knowledge. Adequate knowledge was positively correlated with attitude.

Epilepsy is one of the most common neurological disorders in Saudi Arabia, with an estimated prevalence of 6.54 per 1000 individuals.1 It is estimated that 20-40% of newly diagnosed patients are expected to fail seizure control with medical treatment.2 Refractory epilepsy is commonly defined as the failure to achieve freedom from seizures despite two or more antiepileptic drugs (AEDs).3 Patients with drug-resistant epilepsy (DRE) have a lower quality of life and face more social difficulties than patients with controlled epilepsy.4-6 More than half of the economic burden of epilepsy is accounted for by patients with refractory epilepsy.7 Epilepsy surgery is the best evidence-based treatment option for these patients with drug resistant focal epilepsy.8,9 The current guidelines for patient referral to epilepsy surgery were published in 2003 by the American Academy of Neurology.9 The benefits of epilepsy surgery may not only reduce the frequency of seizures but might also lower mortality and improve the quality of life.10 Despite its proven efficacy and favorable outcome, the average referral delay of an epilepsy surgery candidate is more than 20 years.11 This delay is predominately attributed to non-adherence to referral guidelines, which results from a lack of awareness and familiarity with them.12 Another factor that contributes to the delay is patients’ misbeliefs regarding the surgery’s risks and benefits, which are highly influenced by physicians’ lack of knowledge.13 Epilepsy surgery was introduced to Saudi Arabia in 1998.14 Several epilepsy surgery centers have subsequently been established across the country. A survey in 2013 showed that 56% of health-care professionals in Saudi Arabia were not aware that surgery was a treatment option for patients with epilepsy.15 Our aims in this study were to investigate the levels of knowledge and attitudes toward epilepsy surgery among neurologists in Saudi Arabia and evaluate the factors that affect the physicians’ knowledge and attitudes.     

Adherence to antiepileptic drugs and beliefs about medication among predominantly ethnic minority patients with epilepsy

The current study examined beliefs about medication and their association with adherence to antiepileptic drugs (AEDs) among predominantly ethnic minority, low-income patients with epilepsy (PWE). Seventy-two PWE completed standardized questionnaires. The Beliefs about Medicines Questionnaire was used to assess perceptions about AEDs and medications in general. Adherence was measured with the Morisky 4-item scale and via participant self-rating. On the Morisky scale, 63% of patients endorsed at least one item for nonadherence; forgetfulness was most often endorsed (50%). There was a significant relationship between seizure frequency and adherence (Morisky: r = 0.33, P = 0.006; self-rating: r = − 0.35, P = 0.003). Patients with lower self-rated adherence expressed greater concerns about AEDs (r = − 0.25, P = 0.036) and beliefs that medications, in general, may be intrinsically harmful (r = − 0.26, P = 0.032) and minimally beneficial (r = 0.36; P < 0.002), as compared with more adherent patients. These findings inform future educational interventions in this population of PWE.     

Prevalence and biopsychosocial factors associated with treatment adherence among people with epilepsy in a tertiary care hospital in Riyadh,Saudi Arabia

Objectives:To identify the magnitude of treatment adherence among people with epilepsy (PWE) and the impact of sociodemographic, medical and psychosocial factors on treatment adherence.Methods:A quantitative cross-sectional observational study was performed based on data collected from adult patients attending the epilepsy clinic, King Saud University Medical City, Riyadh, Saudi Arabia. Patients completed paper-based questionnaires including a sociodemographic, cultural, psychiatric history and medical history sections. In addition to that we evaluated treatment adherence by visual-analogue scale (VAS), depressive symptoms by PHQ-9, anxiety symptoms by GAD7, physical symptoms by PHQ-15, attachment style by ECR16 and cognitive impairment by MOCA.Results:A total of 207 patients participated, with a mean age of 34 years;.53.6% were female. The mean patient-reported adherence to their treatment regimen was 81.6%±18.4%. Univariate analysis revealed statistically significant negative associations between depression, anxiety and physical symptoms and treatment adherence. However, multiple linear regression analysis only showed physical symptoms to be a significant predictor for epilepsy medication adherence.Conclusion:Somatic (physical) complaints could be important predictors of treatment adherence in (PWE). This study is one of the first to suggest the importance of targeting physical symptoms in screening and intervention approaches to improve Antiepileptic drugs (AEDs) adherence.

Epilepsy is one of the most common chronic serious neurological diseases and affects approximately 50 million people of all ages worldwide. ¹ The estimated median prevalence of epilepsy in Arab countries is 2.3/1,000 (varying from 0.9–6.5/1,000), which is just within the range found in Europe, North America, Australia, and Asia. ² In Saudi Arabia, the prevalence of active epilepsy is 6.54/1000 population. ³ According to global and local studies, most cases of epilepsy are idiopathic, though it may be caused by cerebrovascular accidents, head trauma, cerebral palsy and CNS infection. ^1,4 The overall mortality rate for (PWE) is increased by two- to threefold compared with the general population. ^1,5,6 In addition, there are high rates of psychological conditions such as depression and anxiety among (PWE). ^7-10 Patients with mood disorders are more likely to be nonadherent with regard to medication. ^8,11–13 The World Health Organization defines medication adherence as the extent to which a patient’s behavior, in terms of taking medications, following a diet, and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider. ¹⁴ Anti-epileptic drugs (AEDs) are the main therapy for epilepsy to prevent seizures. ¹⁵ Indeed, up to 70% of children and adults with epilepsy can be successfully treated with AEDs. ¹ However, the prevalence of significant medication nonadherence in epilepsy has been reported to vary between 26% and 79%. ¹⁶ A cross-sectional study performed locally in Riyadh, Saudi Arabia, at King Fahad Hospital found that 48.7% of patients were nonadherent regarding anti-epileptic medication. In this study, adherence was assessed by asking patients whether they ever missed or stopped their medications, with the most common factor for nonadherence being forgetfulness. ¹⁷ In another local study performed among adolescents with epilepsy conducted cross-sectionally at Riyadh National Hospital in Saudi Arabia, 38.3% were antiepileptic drugs nonadherent, and the most important factors affecting adherence to prescribed medication were the age of the mother, number of family members, number of administered drugs and seizure frequency. ¹⁸ In general, the risk of subsequent seizures among nonadherent patients may increase by 21%. ¹⁹ Nonadherence is also associated with an increased likelihood of hospitalization and emergency room admission and with an over threefold increased risk of mortality compared to adherence. ^20,21 Depression, stress and anxiety are all associated with reduced antiepileptic drug adherence. ^{8,11–13,22–24} Additionally, the results of another study showed that depression measured by another scale (NDDI-E) correlated with an increased risk of AED nonadherence, which led to the same result. ²⁵ Conversely, perceived social support correlated positively with adherence. ²³ In another study, however, neither depression nor family support were associated with adherence. ²⁶ Nevertheless, these studies did not discuss the correlation between attachment style and cognitive function with treatment adherence in patients with epilepsy (PWE). However, multiple studies conducted on other diseases showed an association between attachment style especially avoidance, and reduced adherence to medical treatments. ^27–29 A study at King Khalid University Hospital in Saudi Arabia has addressed the psychosocial predictors of treatment adherence in another neurological disorder, multiple sclerosis, and found that 79.47% of patients were adherent to treatment, with the most significant factor associated with nonadherence being cultural beliefs. ³⁰ To date, there is a lack of research about the psychosocial aspects of epilepsy in Arab countries. ³¹ In fact, none of the local studies we found mentioned psychosocial predictors related to adherence among patients with epilepsy. Hence, this cross-sectional study aims to identify psychosocial predictors, specifically depression symptoms, anxiety symptoms, cognitive impairment, attachment style and cultural beliefs, for treatment adherence among (PWE). Addressing psychosocial problems may help to optimize care for these patients. ³² Overall, identifying barriers to AED adherence is imperative to help practitioners who are developing appropriate strategies to improve adherence rates. ^20,24      

Antiepileptic treatment in patients with epilepsy and other comorbidities

BackgroundA high number of patients with epilepsy have comorbidities. The type of comorbidity is an important factor in deciding on the most suitable treatment, including that for acute epileptic seizures and chronic antiepileptic treatment. Evidence-based criteria should guide the selection of the appropriate antiepileptic drugs given specific comorbidities.MethodsWe performed a comprehensive search of the scientific literature on epilepsy treatment in patients with the following comorbidities: heart disease, lung disease, liver disease, kidney disease, porphyria, organ transplantation, thyroid disease, metabolic disorder, infection, mental disability, psychiatric disorder, cognitive impairment, stroke, and brain tumour.ResultsMost of the studies were case series and retrospective analyses. No randomised controlled trials specifically designed for this type of clinical situation were identified. The level of scientific evidence to guide clinical decisions is therefore low.ConclusionsIn this review we make recommendations based on the best scientific evidence available for treating epilepsy in patients with other comorbidities, including the treatment of epileptic seizures in acute situations as well as chronic antiepileptic treatment. When no scientific evidence is available, our recommendations are based on pharmacokinetic criteria and tolerability of antiepileptic drugs, using accumulated experience and the consensus of the members of the Andalusian Epilepsy Society.     

Prevalence of depression among epileptic patients in Taif City,Saudi Arabia

Objectives:To assess depression and its relation with different factors among people with epilepsy in wider range of ages.Methods:A cross-sectional study was conducted in Taif city. The sample size was 150; the inclusion criteria were ≥18-year-old patients diagnosed with epilepsy. The data were collected by interviewing patients following up from rural and urban areas of Taif in neurology clinics at King Faisal Medical Complex (KFMC) and King Abdul-Aziz Specialist Hospital (KAASH). The PHQ-9 score was used to screen for depression.Results:Our study showed that approximately 76.7% (n=115) of the patients had some form of depression. A severe form of depression was identified in 8.7% (n=13) of the patients, and a moderately severe form was observed in 13.3% (n=20) of the patients. There was no significant association between depression and gender, duration of epilepsy, type of epilepsy, and medications for epilepsy, while there was a statistical association between depression and age, stress level, and employment status (p<0.044, p<0.001, p<0.008, respectively).Conclusion:Depression is common in people with epilepsy. Regular screening for depression is recommended in people with epilepsy for early detection and treatment.

Epilepsy is one of the common neurological disorders in the world affecting people of all ages.¹ Approximately 1.5 and 5% of any population will have afebrile seizures at some time.² The prevalence of epilepsy in Saudi Arabia is 6.54 per 1000.¹ There are many psychiatric comorbidities associated with epilepsy.³ Poor adaptation to the new diagnosis of epilepsy has been found to cause different psychiatric disorders.⁴Depression is one of the most common psychiatric comorbidities in people with epilepsy with an estimated prevalence of approximately 10% in the general population and approximately 30% in people with epilepsy.³ Depression in people with epilepsy is associated with a poor quality of life and a high risk for suicidal ideations compared to people with epilepsy without depression.⁵Li et al³ 2019 determined that 29.9% of epileptics had depression, and 15.8% of them had suicidality. Moreover, a case–control study conducted in Greece determined that the Patient Health Questionnaire (PHQ-9) for the evaluation of depression severity was higher in people with epilepsy compared to that in the control.⁵ Fecske et al⁶ indicated that the prevalence of depression in pediatrics with epilepsy was 15%.In 2016, a study was performed in Taif, Saudi Arabia, which showed that 89% of 12–18-year-old adolescents with epilepsy had depression.⁷ Therefore, the aim of this study was to estimate the prevalence of depression among people with epilepsy and its association with demographic characteristics, type of convulsions, duration of epilepsy and number of medications used, and the stress level within a broader range of population.     

Relatives' beliefs about the causes of schizophrenia

Angermeyer MC, Matschinger H. Relatives' beliefs about the causes of schizophrenia. Acta Psychiatr Scand 1996: 93: 199–204. © Munksgaard 1996. Based on a representative survey among the members of German and Austrian asSociations of relatives of mentally ill people, this paper examines the beliefs commonly held by relatives of persons suffering from schizophrenia concerning the causes of this disorder. A comparison of the information gathered in the course of this survey with the results of a representative survey conducted among the general public in Germany shows that relatives will usually look to biological factors when searching for the cause of schizophrenia, while the general public tends to cite psychosocial factors, especially stress-related factors, in order to explain the development of this illness. We attribute this discrepancy to relatives' greater exposure to the knowledge of psychiatric experts as well as their having to deal with their own feelings of guilt.     

Impact of a family history of epilepsy on the diagnosis of epilepsy in southern Saudi Arabia

PurposeEpilepsy can develop at any age for reasons that remain poorly understood. The aim of this study was to determine the impact of a family history of epilepsy (FHE) on the incidence and recurrence of seizures.MethodsThis retrospective study was conducted in Aseer central hospital, Abha, Saudi Arabia between January and June 2012. The medical records of 420 patients were analyzed to test the impact of FHE on the risk factors, etiology and diagnosis of epilepsy determined by magnetic resonance imaging (MRI) and electroencephalography (EEG).Results420 patients were studied. Idiopathic epilepsy was seen in 140 patients (33%), symptomatic in 152 (36%), and cryptogenic in 128 patients (30%). FHE was seen in 113 patients (27%), which was associated with younger at the disease onset (15 years vs 20 years, p < 0.05). Idiopathic epilepsy was seen more in patients with FHE (43% vs 30%, p value <0.05), and generalized seizures (primary or secondary) were also seen more in patients with FHE (51% vs 36%, p value <0.05). Abnormal EEG was also seen more in patients with FHE (79% vs 66%, p < 0.05). Multivariate regression analysis showed that temporal epileptic discharges were the best predictor for the presence of FHE (p < 0.05, OR = 3.1, 95% CI 1.7–5.8), more than idiopathic epilepsy or younger age at epilepsy onset.ConclusionsFHE has a significant impact on epilepsy, its classifications, and the EEG findings, and may underlie the presence of a genetic etiology, which could be related to a high incidence of consanguinity seen in our population. Temporal epileptic discharges were the best predictor for FHE, which may suggest the presence of familial TLE.     

Patients' perspectives on antiepileptic medication: Relationships between beliefs about medicines and adherence among patients with epilepsy in UK primary care

BackgroundNonadherence to antiepileptic drugs (AEDs) can result in suboptimal outcomes for patients.AimThis study aimed to assess the utility of a theory-based approach to understanding patient perspectives on AEDs and adherence.MethodPatients with epilepsy, identified by a GP case note review, were mailed validated questionnaires assessing their perceptions of AEDs and their adherence to them.ResultsMost (84.9%) of the 398 AED-treated respondents accepted the necessity of AEDs, but over half expressed doubts, with 55% disagreeing or uncertain about the statement ‘I would prefer to take epilepsy medication than risk a seizure’. Over a third (36.4%) expressed strong concerns about the potential negative effects of AEDs. We used self-report and medication possession ratio to classify 36.4% of patients as nonadherent. Nonadherence was related to beliefs about medicines and implicit attitudes toward AEDs (p < 0.05). Adherence-related attitudes toward AEDs were correlated with general beliefs about pharmaceuticals (BMQ General: General Harm, General Overuse, and General Benefit scales) and perceptions of personal sensitivity to medicines (PSM scale).ConclusionWe identified salient, adherence-related beliefs about AEDs. Patient-centered interventions to support medicine optimization for people with epilepsy should take account of these beliefs.     

Religiosity aspects in patients with epilepsy

The objectives of this study were to assess religiosity aspects in patients with epilepsy (PWEs) and controls and to determine whether such aspects were related to the samples' clinical, sociodemographic, and QOL-31 data. The Duke Religion Index was administered to 159 adult PWEs and 50 controls. The relationships between the Duke Religion Index and the study variables of the two groups were compared. Intrinsic religiosity (IR) and nonorganizational religiosity (NOR) were higher in PWEs than in controls. Logistic regression showed that being female (p = 0.022) and having mesial temporal lobe epilepsy with hippocampus sclerosis (MTLE-HS) (p = 0.003) were predictors of high organizational religiosity (OR) and that high NOR was associated with MTLE-HS (p = 0.026) and controlled seizures. Further, only MTLE-HS (p = 0.002) was predictive of high IR. The Duke Religion Index and QOLIE-31 scores were not related. Different forms of interictal religiosity are related to clinical aspects of epilepsy.     

Spirituality aspects in patients with epilepsy

PurposeDo epilepsy and spirituality interact? This study aimed to determine whether an easy-to-administer scale, such as the spirituality self-rating scale (SSRS), could detect increased religiousness in people with epilepsy and verify how epilepsy influences spirituality.MethodsA total of 196 consecutive patients with epilepsy (epilepsy group, EG) with a mean age and standard deviation of 46.5 ± 14.8 years and 66 subjects with no history of neurological or other chronic disorders (control group, CG) were assessed by the SSRS and neurologically.ResultsThe SSRS scores of the EG and CG did not differ significantly (22.8 ± 5.1 and 22.0 ± 5.7, respectively). Patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS) had significantly higher SSRS scores than those with other epileptic syndromes and, than in individuals of the CG. Multiple regression showed that the factors significantly associated with greater spirituality (greater SSRS score) for the EG, were lower education level, abnormal background EEG activity, and MTLE-HS. Other relationships with the clinical features of epilepsy and with the presence of psychiatric co-morbidity were not found.ConclusionThe present findings do not confirm a specific role of epilepsy in spirituality or of “epileptic hyperreligiosity,” but suggest that spirituality in people with epilepsy is influenced by education level, and may also stem from epilepsy-related factors such as abnormal background EEG activity and the presence of MTLE-HS.     

Prevalence of depression and anxiety among adult patients with multiple sclerosis at Riyadh City,Saudi Arabia

Objectives:To determine the prevalence of depression and anxiety in adult multiple sclerosis patients attending tertiary facilities in Riyadh, Saudi Arabia.Methods:This is a cross-sectional study conducted among MS patients in Riyadh City, Saudi Arabia. A self-administered questionnaire was distributed among MS patients at Prince Sultan Military Medical City in Riyadh, Saudi Arabia between April 2020 and January 2021. The questionnaire consisted of socio-demographic characteristics and the Hospital Anxiety and Depression Scale (HADS). Univariate using Chi-square test and multivariate regression analysis had been performed to determine the factors associated with anxiety and depression among MS patients.Results:A total of 328 MS patients took part in the study. The most prevalent age group was 36–45 years old (38.4%), with over 70% of the participants being females. Anxiety and depression were shown to be prevalent in MS patients at 42.9 percent and 58.8 percent, respectively. According to statistical tests, being less educated and having partial to severe disability was linked to an increased rate of anxiety and depression, whereas being female was more prone to anxiety symptoms but not depression.Conclusion:Depression was more frequent than anxiety. As a result, while assessing psychiatric diseases in the study group, depression/anxiety may be expected to be more frequent amongst those of greater disability.

Multiple sclerosis (MS) is a central nervous system demyelinating disease caused by an immunological response. Depression and anxiety are more common in patients with multiple sclerosis (PWMS) than in the general population, ^1-4 which is a well-known phenomenon. However, we believe that these illnesses are under-recognized in PWMS because several MS symptoms overlap with depression and anxiety, making detection more difficult. Fatigue, sleeplessness, anorexia, memory loss, and concentration problems are all common symptoms of depression, MS, or both. ^5,6 Furthermore, the symptoms of MS might mislead self-report rating scales designed to detect depression and anxiety, resulting in false positives or negatives. ^5,6 Moreover, depression in PWMS can impair their quality of life (QOL), medication adherence, and compliance, worsening their prognosis. ^7-9 Suicidal thoughts and attempts are also common. ^10-13 The hospital Anxiety and Depression Scale is a one-of-a-kind measure for detecting anxiety and depression while taking into account both disorders’ possible confounders, and it has been validated for use in PWMS. ⁶ Depression is a significant mood illness that affects many people. It creates severe symptoms that impact how you feel, think, and handle day-to-day tasks like working, sleeping, and eating. ¹⁴ In PWMS, the lifetime prevalence of depression in up to 50%, ³ compared to 10.8% in the general population. ¹⁵ The cause of depressive disorders in people with MS is unknown. However, it is assumed to be complex, with psychological, social, and neurological aspects - as well as immunologic and genetic factors - all having a part. ¹⁶ Furthermore, depression can have a severe impact on these patients’ health by raising the severity of their symptoms and reducing their compliance with therapy and follow-up, both of which have an impact on their medical costs. ⁹ In addition to a decreased quality of life (QOL), cognitive impairment, and an increased risk of suicide, especially when anxiety is present. ^7,10,11 Furthermore, PWMS have a 10-year lower life expectancy than the general population of the same age. ² Patients, caregivers, and care providers should not underestimate the impact of sadness and anxiety on PWMS. Improved identification, diagnosis, and treatment in medical offices, where people with mood disorders are frequently seen for the first time, can assist to improve these negative outcomes. ¹⁷ Unfortunately, despite convincing evidence of its high incidence, greater influence on prognosis, and quality of life, depression and anxiety are still underdiagnosed and undertreated. ¹³ The goal of this study is to find out how common depression and anxiety are among adult patients with multiple sclerosis in Riyadh, Saudi Arabia. We’ll also see if there’s a link between Hospital Anxiety and Depression Scale (HADS) score and patients’ demographical, socio-educational, and MS-related characteristics, as well as MS duration, Immunomodulatory type, and EDSS scores.     

Adherence to treatment in patients with epilepsy: associations with seizure control and illness beliefs.

OBJECTIVE: This study investigated non-adherence to antiepileptic drug treatment amongst patients with epilepsy in secondary care. The associations between adherence and seizure control, perceptions of illness and medication, anxiety and depression were also examined. METHODS: A cross-sectional study of fifty-four patients with epilepsy were recruited from a hospital epilepsy clinic. RESULTS: Fifty-nine percent were estimated to be non-adherent to medication. There was a negative correlation between adherence and frequency of seizures. Patients with poorly controlled epilepsy were more anxious, and expected a longer duration of their epilepsy. CONCLUSION: Assessment of adherence should be a routine part of management of epilepsy. Further recognition and support should be given to patients who have poor seizure control since they are more likely to be more anxious and have unhelpful illness and treatment beliefs.     

Knowledge,attitudes, and beliefs about epilepsy and their predictors among university students in Jordan

The aim of this cross-sectional study was to assess the knowledge about epilepsy and the attitudes toward people with epilepsy (PWE) and their predictors among university students in Jordan. A self-administered questionnaire was distributed in three of the largest public universities in Jordan, and a total of 500 questionnaires were collected from each university. The number of students who reported that they had heard or read about epilepsy was 1165 (77.6%), and their data were analyzed. A significant proportion of students thought that epilepsy could be caused by the evil spirit (31.5%) and the evil eye (28.1%) or that it could be a punishment from God (25.9%). Epilepsy's most commonly reported treatment methods were the Holy Quran (71.4%), medications (71.3%), and herbs (29.3%). The most common negative attitudes toward PWE were that the students would refuse to marry someone with epilepsy (50.5%) and that children with epilepsy must join schools for persons with disabilities (44.4%). Male students, students of humanities, and students with a low socioeconomic status tended to have more negative attitudes toward PWE. In conclusion, many students have misconceptions about the causes, treatment, and nature of epilepsy, and students have moderate negative attitudes toward PWE. Universities should have health promotion programs to increase awareness of their students about major public health problems such as epilepsy.     

Public beliefs about the causes of mental disorders revisited

When the lay public is asked to prioritize their causal beliefs for a vignette depicting either schizophrenia or depression, psychosocial causes are most popular for depression, but a large proportion of respondents prefers biological causes for schizophrenia. Recognition of the vignette as mental illness enhances the likelihood to endorse brain disease as a cause and reduces choices of certain psychosocial causes.