Prototypes of People With Depression

This article investigates the content and the consequences of the prototypes of people with depression in a multimethod fashion. Fourteen preregistered studies (total N = 5,023, with U.S. American, British, and French adult participants) show that laypeople consider people with depression as having specific psychological, social, and physical features (e.g., unattractive, overweight, unsuccessful, introverted). Target prototypicality influences how much laypeople believe others have depression, how much observers believe that depression-like symptoms cause someone to experience psychological pain, and how much professional mental health care is appropriate for others. This effect was not reduced by instructing people to focus on the symptoms and ignore the target features yet was weakly reduced by informing them of the effect. We discuss theoretical implications for the understanding of prototypes of people with depression and practical implications for alleviating the impact of prototypes.

people with mental illness, particularly people with depression (Cox et al., 2012;Link et al., 1999;Star, 1955).Most of this research, however, investigated how laypeople (Byrne, 2000;Corrigan & Kleinlein, 2006;Lauber, 2008;Link et al., 1999;Link & Phelan, 2001;Norman et al., 2008;Rüsch et al., 2005) and professionals (Lauber et al., 2006;Nordt et al., 2006) stigmatize people with mental illness, with the objective of reducing stigmatization to improve access to care and integration of people with mental illness into society (Byrne, 2000).This research focused on observers' reactions to someone they believed as having depression (Lauber, 2008) or on the schemas that people with depression have of themselves (Beck, 1967;Cox et al., 2012) but neglected to investigate the content of the prototype of people with depression.This includes lay beliefs about what people with depression look like and how they behave, including a variety of psychological, social, and physical features.The present investigation aims to fill this gap in the literature.

Potential Contents of Stereotypes of People With Depression
When clinicians make diagnoses for depression, they use an established set of criteria (e.g., those described in the Diagnostic and Statistical Manual of Mental Disorders-5 [DSM-5;American Psychological Association, 2013] or the International Classification of Diseases 11th Revision [ICD-11;World Health Organization, 2022]).When using these criteria, they evaluate whether individuals experience a certain number of symptoms for a prolonged period and whether these symptoms also cause distress and/or impairment in social and psychological functioning.However, when laypeople categorize someone as having depression, they might use much less complex information.We aim to understand what information laypeople use to recognize someone as having depression.
Most stereotypes about people with depression are negative, including being needy, dependent, helpless, and unpredictable but also being strange, aggressive, and dangerous (Angermeyer & Matschinger, 2003).On the one hand, negative stereotypes about people with depression are thought to come from the media, where inaccurate and inappropriate views of people with depression are widespread (Goepfert et al., 2019).For instance, research shows that the news media implies that people with depression were responsible for their condition (Zhang et al., 2016).On the other hand, 97% of the symptoms about depression in Australian media items mentioned in relation to depression were accurate (Francis et al., 2005), which might be due to the increasing levels of mental health literacy campaigns ( Jorm et al., 2005).

Recognizing Depression and Its Consequences
Laypeople (especially close others, like partners, family, or friends) often recommend others to seek treatment for depression ( Jorm et al., 2005;Link et al., 1999).Laypeople may not consider someone to have depression despite the presence of symptoms because this person may not fit the person-with-depression prototype.Then, it might be more likely that the person with depression will not seek treatment.Further, observers may minimize symptoms among people with depression, which might compound their suffering (Ormel et al., 1991).It is unclear what information people use to recognize depression (but see N. S. Kim and Ahn, 2002) and whether they rely on prototypes of people with depression or the clinical symptoms.This article aims to fill this gap as well.
When people's features do not conform to a certain prototype, observers are less likely to judge what is happening as a prototype-linked behavior.For instance, because people believe that the prototypical woman victim of sexual harassment is conventionally feminine,

Statement of Relevance
How do people imagine people with depression, and does this affect how laypeople understand depression symptoms?We asked U.S. American, British, and French adult participants and found that they had a multifaceted prototype of people with depression.Laypeople imagined people with depression with specific physical, social, and psychological features (unattractive, overweight, unsuccessful, introverted).People thought that if someone did not fit the prototype, the same symptoms (e.g., lack of sleep, continuous sad mood) were less indicative of depression, that they would experience less psychological pain, and that mental health care would be less appropriate for them.It was hard to correct these perceptions, and interventions yielded only small reductions of the effects of prototypes.These findings are important to show what people believe a people with depression should look like and how they would behave when someone who does not fit the prototype of the person with depression shows potential depression symptoms.they are less likely to categorize ambiguous behaviour as sexual harassment when directed to a less feminine woman (Goh et al., 2021).Similarly, if people do not believe that someone fits their prototype of a person with depression, they might be less likely to interpret the same symptoms as indicative of depression.This may also lead them to discount the target's suffering and to be less likely to recommend mental health care as a solution to the symptoms.Therefore, another goal of this article is to test the effect of prototypicality on the classification of a person as having depression.
Some researchers argue that when diagnosing depression, it makes sense to consider information that is not strictly included in diagnostic instruments.This is because diagnoses and diagnostic instruments are varied and unreliable (Fried et al., 2022) and should not be blindly relied on, lest we fall into "diagnostic realism" (i.e., mistaking diagnoses for syndromes) (Kendler, 2016;Kendler et al., 2011).Further, because mental illnesses are biopsychosocial diseases, researchers have argued that to diagnose someone with MDD, mental health care professionals should take into account a larger variety of patients' features and not just the symptoms described in diagnostic manuals such as the DSM-5 or the ICD-11 (Fried, 2022).Without taking a position on the cues that should be taken into account when diagnosing depression, the present investigation can help this debate by cataloging some of the features that make laypeople more likely to classify someone as having depression.
Finally, can the effect of prototypes be reduced?For instance, making people aware of the importance of depression prototypes on classification of a person as having depression might reduce their overreliance on personal features.In addition, explicitly instructing people to ignore personal features and focus on the symptoms alone may also moderate the effect of depression prototypes on classification as depression (a similar method was used to reduce people's reliance on extraneous cues in Dietvorst &Simonsohn, 2018, andin Ziano &Wang, 2021).We also test these ideas.

Study Overview
We conducted 14 studies with British, U.S. American, and French participants (total N = 5,023; summarized in Table 1; we present Study 1a to Study 3 fully in the article).Studies 1a, 1b, 1c, and S1 to S7 investigated the social, psychological, and physical features that lay observers believe people with depression have.Study 2 and Study S8 tested whether target features influence the recognition of depression, the amount of perceived psychological pain, and the perceived appropriateness of mental health care.Study 3 and Study S9 tested whether receiving information about the effect of stereotypes or instructing participants to focus on the symptoms (and ignore targets' features) can decrease the influence of prototypicality on recognition of depression, the amount of perceived psychological pain, and the perceived appropriateness of mental health care.

Method
In Study 1a, we asked participants to write down two physical, two social, and two psychological features of people with depression (six total features).In Study 1b, we asked participants to write down three features instead of two per the same categories.

Results and discussion
The data resulted in 1,200 entries in Study 1a and 2,223 in Study 1b.In Study 1b, some participants completed the entries in French.A bilingual author translated them to English before they were coded by the coders.There were three steps in the coding procedure.First, both authors went through the data and inductively proposed categories.Next, two independent coders, blind to the aim of the study, used the generated categories to separately code the data.Using this coding, we calculated the Kappa scores for each target feature category (i.e., physical, social, psychological) and altogether.All Kappa scores showed high agreement across the two coders (see Table 2).Finally, the coders discussed and agreed on a final coding for the disagreements.Results from the final coding are summarized in Table 3 along with the most frequent few words in each category.Word clouds based on the results are presented in Figures 1 and 2. This establishes the content of prototypes of people with depression across two different samples in two countries, at a qualitative level.In the next studies, we explore it in a quantitative fashion.

Study 1c: Eliciting Prototypes of People With Depression in a Quantitative Fashion
The objective of this study was to elicit prototypes of people with depression and compare them with imagined features of people explicitly described as without depression and with a control condition where no depression symptoms are specified.Unlike Studies 1a and 1b, in Study 1c we added the trait "successful" because we believed it was interesting and relevant for life in organizations and omitted traits relative to the negative psychological state (e.g., anxious, sad) of Instructing participants to ignore features and focus on recent symptoms is not enough to reduce the impact of prototypical depression features on perceptions of depression by laypeople.Strikingly, this happens while participants report to be focusing on symptoms rather than on features a Before/after exclusions.Sample sizes were decided by aiming for at least 80 participants per cell in two-cell between-subjects designs and 150 per cell in designs that had more than two cells in which we forecast corrections for multiple comparisons.
the person because we believed that they were confounded with the symptoms presented in the ICD-11 or DSM-5 classification.

Method
Participants were randomly assigned to one of six conditions in a 3 (symptoms: depressed vs. not depressed vs. no information) × 2 (target gender: male vs. female) fully between-subjects design.First, participants were assigned to either the male or the female target condition.In the male condition, they read the following scenario: Jonathan Smith is a bank clerk at LMS, a bank in New Orleans, Louisiana.He is originally from Houston, Texas.Jonathan is 38, has an associate degree in management, and is Caucasian.
In the female condition, the name and the pronoun were changed to female: Jessica Smith is a bank clerk at LMS, a bank in New Orleans, Louisiana.She is originally from Houston, Texas.Jessica is 38, has an associate degree in management, and is Caucasian.
Then, participants were assigned to either the depressed condition, the nondepressed condition, or the no-information condition.Participants in the noinformation condition proceeded to the next part of the survey (i.e., the measures) without reading any additional text.
Participants in the depressed condition read the following: This person is clinically depressed.They often have insomnia and are in a state of a really bad mood.
Participants in the nondepressed condition read the following: This person is not depressed.They have their up and downs like everyone but are overall quite OK psychologically speaking.
Measures.Then, participants replied to six questions in random order.To test what the physical features of the prototype, we asked, "Do you think this person is overweight?" and "Do you think this person has an attractive face?"To test the psychological features of the prototype, we asked, "Do you think this person takes care of themselves?" and "Do you think this person is introverted or extroverted?"To elicit a social dimension of the prototype, we asked, "Do you think this person is successful at work?"As a manipulation check, we asked, "Do you think this person is clinically depressed?"All questions were anchored at 1 (not at all) and 7 (very much), except for the introversion question, which was anchored at 1 (very introverted) and 7 (very extroverted).

Results
We did not find any interaction between symptoms and target gender for any dependent variable.Here and in all studies where we performed analyses of variance (ANOVAs), we report Tukey-corrected pairwise comparisons.Full statistical analyses are available on OSF.These results are depicted in Figure 3.This study shows that people imagine people with depression as more overweight, less attractive, more introverted, less successful, and taking care of themselves less compared with both people who are explicitly described as nondepressed and control targets for which no specifications about depression are offered.The nondepressed and the no-information conditions were quite similar to each other across dependent variables.
Studies S1 to S7: Extending and Testing the Robustness of the Prototype Across Features, Study Designs, and Populations

Results
It is important to test the generalizability of these results to different scenarios (different jobs, age, names) and participants from different countries.For this, we conducted Studies S1 to S7. Full details are available at https://osf.io/2f8yn/?view_only=8ac1f586d72f4a33af6ff 84a5c44227b.
Studies S1 to S6 had a between-subjects design with two conditions, and participants read a short description of a person followed by the information either that they were diagnosed with depression or that their mental health was fine.Study S1 shows that U.S. American participants imagined a depressed welder as owning fewer luxury clothes than a nondepressed one (p = .012,

Method
The goal of this study was to test whether prototypical target features influence the recognition of depression, the amount of perceived psychological pain, and the perceived appropriateness of mental health care when depression symptoms are kept constant across the conditions.Moreover, we tested the potential moderating role of mental health stigma.Participants were randomly assigned to one of three conditions (between subjects): control, prototypical, counterprototypical.All participants read this introduction: Below, a woman who is 41 years old and lives in the Los Angeles area is described.This person's initials are S.K., and she works at a social media company.
Only participants in the prototypically depressed condition then read the following description: S.K. is not successful in her job, does not take care of her looks, is quite overweight, is physically unattractive, and is quite introverted.
Participants in the counterprototypically depressed condition read the following instead: S.K. is successful in her job, takes care of her looks, is in good physical shape, is physically attractive, and is quite extroverted.
Participants in the control condition were not given any information about S.K.'s features and read only about S.K.'s recent symptoms, taken from the ICD-11 (World Health Organization, 2022), as did all the participants in the prototypical and counterprototypical conditions as well: For the past 4 weeks or so, this person has felt quite sadder than normal and could not get to sleep as well as they would have in the past.
Measures.After reading the scenario, participants completed three outcome variables, anchored at 1 (not at all) and 7 (very much): "How much psychological pain do you think this episode caused to this person?"as a measure of perceived psychological pain caused by the episode (we focused on psychological pain because we believed that recognizing pain in others might be the first step to recognizing whether they are depressed and further to recommending them mental health care); "Do you think this person is clinically depressed?"as a measure of classification as depression; and "Do you think this person should seek professional help for mental health?" as a measure of the appropriateness of seeking professional mental health help.Either before or after reading the scenario (we randomized the order), participants completed a short version of the Personal subscale of the Depression Stigma Scale (Griffiths et al., 2004) on seven 5-point Likert items.This scale showed good reliability (Cronbach's α = .82),and we averaged it in a stigma scale index to test its potential moderating effect.

Appropriateness of professional mental health care.
Participants believed that professional mental health care was more appropriate for the prototypically depressed target (M = 5.70, SD = 1.26) compared with both the Impact-of-stigma scale.We found that the stigma scale was negatively correlated with all dependent variables.This means that people higher on the stigma scale (i.e., those who were more likely to stigmatize mental health care) were less likely to rate the targets as having depression, to believe that they were in psychological pain, or to recommend mental health care.Importantly, we could not find a significant interaction between target features and the stigma scale on any of the three dependent variables, suggesting that the stigma scale and prototypes have independent effects (see Table 5).These results show that prototypes of people with depression influence laypeople's view of depression compared with a control condition and with a counterprototypical condition.Even though all participants read the clinical symptoms of depression for each target, it seems they relied on the prototypical information to evaluate the target rather than the symptoms of depression as listed in the ICD-11.We found no interaction between participants' level of stigma toward depression and target features, indicating that prototypes of people with depression and stigmatization are largely independent constructs.To verify the robustness of these results, we also conducted a replication (Study S8, in the Supplemental Material) in which we randomly assigned participants to judge either a female or a male target, and target gender did not moderate these results.In the next study, we tested whether simply informing participants that prototypes exert influence on depression recognition could reduce the effect of prototypes.We also added affiliation measures to test whether information about the effect of prototypes could reduce social isolation of prototypical people with depression.

Method
The goal of this study was to test whether the effect of prototypes can be reduced by informing participants of the influence of prototypes.
We manipulated two factors between subjects: target features (prototypical vs. counterprototypical) and information about the impact of prototypes (shown vs. not shown) on judgments.Participants were therefore randomly assigned to one of four conditions.Participants read the following introduction: Below, a person who is 41 years old and lives in the Los Angeles area is described.This person's initials are S.K.
Then, participants in the prototypical condition read the following description: A woman is not successful in her job, does not take care of her looks, is quite overweight, is not physically attractive, and is quite introverted.

Participants in the counterprototypical condition read the following description instead:
A woman is successful in her job, takes care of her looks, is in good physical shape, is physically attractive, and is quite extroverted.
All participants read the following symptoms: For the past 4 weeks or so, this person has felt quite sadder than normal and could not get to sleep as well as they would have in the past.
Then, participants in the no-information condition proceeded to the measures, whereas participants in the information condition were shown the following: Note: Research has shown that most people consider the same symptoms (e.g., sadness and lack of sleep) as more indicative of depression if the people who have such symptoms fit the prototype of a person with depression (for instance, they are not successful in their job; do not take care of their looks; are physically unattractive, introverted, and overweight), compared with people who do not fit the prototype of a person with depression (for instance, they are successful in their job; take care of their looks; are physically attractive, extroverted, and in good physical shape).Take this into account when replying to the following questions.
Measures.Then, participants were asked six questions, all anchored at 1 (not at all) and 7 (very much).The first three were the same questions about classification as depression, perceived psychological pain, and appropriateness of mental health care asked in previous studies.The second three measured desires of social affiliation with the target ("Would you want to be friends with this person?""Would you want to be colleagues with this person?""Would you want to be neighbours with this person?")and were averaged in an index (α = .91;this decision was not preregistered).

Results
Classification as depression, psychological pain, appropriateness of mental health care.Analyzing the three measures individually with two-way ANOVAs, we found similar results, with large and strong effects of target features, which replicate prior results (all η 2 > .09,all p < .001),and small interactions between target features and information (pain, p = .063,η 2 = .005;classification as depression, p = .024,η 2 = .007;appropriateness of mental health care health, p = .16,η 2 = .003),showing that the effect of target features was somewhat reduced in the shown-information condition.For the classificationas-depression measure, there was a large difference between the counterprototypical (M = 3.65, SD = 1.31) and the prototypical condition (M = 5.26, SD = 1.39) when information was not shown (p < .001,d = 1.17).The difference between the counterprototypical (M = 3.83, SD = 1.39) and the prototypical condition (M = 4.94, SD = 1.41) was slightly but significantly reduced when information was shown (p < .001,d = 0.80).Results are depicted in Figure 5.
These analyses show that receiving information may somewhat decrease the effects of prototypical-target features on classification as depression.This study adds an important kink to our empirical argument by showing that information can be a viable avenue to somewhat reduce the effect of prototypicality, albeit perhaps with a stronger formulation than the present one.Study S9 (on OSF) shows that instructing participants to ignore target features and focus on symptoms did not

Information Shown
Information Shown moderate the effect of prototypes on the same dependent variables used in this study.

General Discussion
In 14 preregistered studies with French, British, and U.S. American adult participants, we investigated the contents of the prototypes of people with depression in a qualitative and quantitative fashion, and the consequences of these prototypes on how laypeople diagnose and understand depression, and conducted two interventions to reduce the effects of prototypes.We found that laypeople imagine people with depression as having different social, psychological, and physical features compared with nondepressed people, which come together in a multifaceted prototype of the person with depression.These prototypes greatly influence how laypeople view depression symptoms: The same symptoms are considered more indicative of depression when the target experiencing them fits the prototype compared with when they do not or when people have limited information (i.e., a no-information condition).Informing participants of the phenomenon regarding prototype-symptom fit weakly moderated the effect.Explicitly instructing participants to ignore the target's features and focus on the symptoms did not reduce the effect.

Theoretical and practical implications
The present work has theoretical implications for the understanding of prototypes (Niedenthal et al., 1985).According to Fehr (1988), once a social category is activated, some features of this category is more central and accessible in memory.This article shows that features linked to stereotypes of people with depression are perceived more prototypical for classification of depression (and its consequences) than the actual symptoms of depression.Previous research investigated prototypes of specific categories (Stiegert et al., 2021), especially of victimized or stigmatized people (Goh et al., 2021;Greitemeyer, 2008); the present article contributes to this research line, showing that people have precise and multifaceted prototypes of people with depression.We also advance the understanding of lay theories of mental health (Corrigan & Kleinlein, 2006;Rüsch et al., 2005).Previous research (Barney et al., 2009;Griffiths et al., 2004) focused on the stigma placed on people with mental illness.This article shows that prototypes of people with depression influence judgments about people with depression, seem independent from stigma, and have very specific contents.Importantly, they affect judgments around depression even when people are instructed to resist or ignore them.In general, the present work bridges literatures about prototypes in social psychology and the lay recognition of mental illness in clinical psychology, which have largely proceeded in parallel (but see Cox et al., 2012, andK. Kim &Ahn, 2018).The present work also has practical implications for the recognition of depression by laypeople (Link et al., 1999;Ormel et al., 1991) and for how the general public understands mental illness (Star, 1955).When diagnosing, professionals might be right to integrate symptoms with other features of the patient to avoid the trap of diagnostic realism; Kendler et al., 2011).However, our results also suggest that when targets do not fit the prototype of a person with depression (e.g., they are successful or attractive), people may not think of them as having depression, and they might remain undiagnosed because people around them are less likely to recommend mental health care.Further, their psychological suffering may be minimized by others, exacerbating the consequences of depression.

Limitations
This article has several limitations.For instance, we did not ask our participants what they thought of the age, gender, and race of the typical person with depression; therefore, we cannot claim that this article studies a universal prototype of people with depression.Second, we tested our hypotheses with laypeople; future research might test the prototype contents and its consequences in a sample of mental health professionals (e.g., psychiatrists, psychologists) to see whether they are similar to those in the lay population (as in Lauber et al., 2006).Third, we recruited participants from the United States, United Kingdom, and France, all Western, rich countries.It is possible that in populations that are not Western and rich (e.g., in Japan or Nigeria), prototypes of people with depression might be qualitatively different.It is also possible that our results might be different in populations with different socioeconomic features compared with those from which we drew.Moreover, our quantitative studies used only scenario-based survey experiments; more naturalistic observations may yield different results.Next, we focused on specific definitions of symptoms and depression, and specific features in prototypes.Using a different set of symptoms and modifying the features used in the prototypes might have different impacts on perceptions.Finally, it is possible that people have different prototypes for mental illnesses that are not depression (e.g., anxiety disorder or schizophrenia), which might have different content and consequences.We hope future research will further investigate these questions and bring new insights into the study of prototypes of depression.

Fig. 3 .
Fig. 3. Imagined features of people with depression (vs.targets explicitly described as without depression and without information about their mental state), Study 1c.Means and 95% confidence intervals are depicted.

Fig. 4 .
Fig. 4. The impact of prototypicality on classification as depression, perceived psychological pain, and appropriateness of seeking professional mental health care, Study 2. Means and 95% confidence intervals are depicted.

Study 3 :
Attempting to Reduce the Effect of Prototypes by Informing Participants of the Effect Itself

Table 1 .
Overview of the Studies in the Present Article

Table 2 .
Kappa Values and Percentage Agreements Between Two Coders,

Table 4 .
Results of Studies S1 to S7 Note: All measures were taken on scales ranging from 1 to 7 (except height in S2, which was measured on 22-point scales, in inches; see materials on the OSF page).*p < .05. ***p < .001.

Table 5 .
The Impact of Stigma Scale and the Stigma Scale by Condition on the Three Dependent Variables