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WELL WHAT DO YOU THINK (2004): THE SECOND NATIONAL SCOTTISH SURVEY OF PUBLIC ATTITUDES TO MENTAL HEALTH, MENTAL WELL-BEING AND MENTAL HEALTH PROBLEMS
EXECUTIVE SUMMARY
introduction
1. The National Programme for Improving Mental Health and Well-Being was established in October 2001 as part of the Scottish Executive's commitment to health improvement and social justice. The National Programme works nationally and locally to raise the profile of, and to support action in, the following key areas:
preventing suicide in Scotland
eliminating stigma and discrimination
raising awareness and promoting positive mental health and well-being
promoting and supporting recovery from mental ill health.
2. To help inform the work of the National Programme and to collect relevant baseline data, the Scottish Executive commissioned the first National Scottish Survey of Public Attitudes to Mental Health in 2002. The survey was designed to be replicable, and was intended to be used as a vehicle for tracking progress towards achievement of the National Programme's aims.
3. In the two years since the first survey was conducted, a number of developments have altered the context within which debates on mental health take place. The National Programme has been working towards the elimination of stigma, through the national anti-stigma campaign 'see me,' and towards establishing an infrastructure to support 'Choose Life,' the national strategy and action plan to prevent suicide. A Scottish Recovery Network is being developed to create awareness and understanding of the concept of recovery from mental health problems and to contribute to the development of values, conditions, environments and relationships which support recovery. A programme of Mental Health First Aid training developed and successfully implemented in Australia has been adapted for a Scottish audience and piloted across all service sectors and among mental health service users, their carers and the general public. To support the continuation of the National Programme's work through to 2006, 24 million in funding is being provided through the Health Improvement Fund.
4. The National Programme is located in the Scottish Executive's new Mental Health Division and is part of the Division's strategy to work with Ministers and all relevant stakeholders to promote attitudes and behaviour in the general public which lead to mental well-being; and to ensure that good quality mental health services are available for everyone who needs them. The 2003 Partnership Agreement reaffirmed the Executive's commitment to improving mental health services across Scotland (Scottish Executive 2003d) and the new Mental Health (Care and Treatment) (Scotland) Act 2003 is intended to provide a fair and effective legal framework to support mental health service provision.
5. Against this backdrop, and following a competitive tendering process, the Scottish Executive commissioned MORI Scotland to conduct the Second National Survey of Public Attitudes to Mental Health, Mental Well-Being and Mental Health Problems. The over-arching aims of the new study were to:
examine the views of a representative sample of the adult Scottish population on a range of mental health-related issues; and
compare findings with other relevant survey data and, in particular, findings from the 2002 survey, in order to track changes in perceptions and attitudes.
6. The survey was conducted face-to-face in respondents' homes between 24
th May and 12
th August 2004. The sample size was 1,401.
general health and lifestyle
7. Most respondents (83%) rated their general health as good or very good. The most positive self-assessments of health were made by people in younger age groups (particularly those aged between 16 and 34 years) and those living in affluent areas, people who had a higher than average annual income or who reported high levels of social engagement. Findings were similar in 2002.
8. Although more than 8 in 10 respondents gave a positive assessment of their own health, 31% of the sample said they had a long-standing illness, disability or infirmity. Of this group, two thirds (20% of the full sample) said that their condition limited their activities in some way.
9. The majority of respondents (87%) said that they were satisfied with their neighbourhoods. The highest levels of satisfaction were reported by older respondents, particularly those aged 75 years and over, while the lowest levels were reported by people who lived in less affluent areas or who reported lower levels of social engagement.
10. Most respondents (83%) said that they saw their friends or relatives more than twice a week. In general, women tended to report more contact with friends or relatives than did men, and people in younger age groups were more likely to see friends and family regularly than were older people. Half of respondents said that they regularly attended social or leisure events or facilities. Almost a quarter of the sample (predominantly women and younger people) said that they had given up time as a volunteer or organiser. Nine per cent of people said they attended a local community or representative group, with older people being more likely to report this type of activity than people in younger age groups.
11. The majority of people in the sample said that they had people they could turn to for help if they were ill (94%) or in financial difficulty (88%). However, respondents who indicated lowest levels of social engagement, those who had an illness that limited their activities in some way, or who said they had experienced a mental health problem were the most likely to say that they had nobody they could turn to in times of difficulty.
mental health and well-being
12. Respondents were asked to complete the GHQ 12, a validated screening instrument designed to detect possible psychiatric morbidity in the population, through their responses to 12 questions about general levels of happiness, anxiety and sleep disturbance. The majority of respondents (82%) were assessed as exhibiting few signs of possible mental health problems (hereafter 'low GHQ 12 scores'). However, almost a fifth of the sample (18%) scored 4 or more (the threshold used to identify respondents showing signs of possible mental health problems; hereafter 'high GHQ 12 scores'). This finding is consistent with other studies, for example the 2002 Scottish House Condition Survey.
13. The factors most commonly identified as having a
positive effect on mental health and well-being (unprompted) were: supportive relationships with family, friends or partners, leisure activities, exercise and having enough money or a good income. The main factors considered to have a
negative effect included physical illness, not having enough money, or being on a low income. 'Work' was commonly identified by respondents as both a positive and a negative factor. These findings are consistent with findings in the 2002 survey.
14. The majority of respondents (66%) felt that they had complete, or a good deal of control over the factors that might affect their mental health. Men and younger people were the most likely to perceive themselves as being in control, as were people who found it easy to manage on their income. Those with high GHQ 12 scores were among those least likely to feel in control, as were people who said they had experienced a mental health problem. There was also a positive correlation between levels of control and social engagement. The most engaged respondents were significantly more likely to feel in control than less engaged groups. Perceived levels of control were slightly, but significantly, lower in this survey than they were in 2002.
experience of mental health problems
15. Approximately three in five respondents (62%) said that someone close to them had been diagnosed with a mental health problem at some stage in their lives. This finding was the same as in 2002. Women were more likely than men to say they knew someone who had experienced a mental health problem, and people in younger age groups were more likely to do so than older respondents, especially those aged 75 years and over. As in 2002, the conditions which respondents had most commonly experienced in someone close to them were depression, panic attacks and Alzheimer's Disease.
16. A quarter of all respondents (26%) said that they had personally experienced a mental health problem. This was almost exactly the same percentage as recorded in the 2002 survey. The most commonly experienced conditions were depression, panic attacks and severe stress. Women, particularly those in the 35-54 years age group, were among those most likely to say they had experienced a mental health problem, as were people who found it difficult to manage on their income and people with high GHQ 12 scores.
17. Respondents who said they had experienced a mental health problem were asked about any difficulties they had experienced in terms of other people's attitudes to them. As in 2002, the majority said they had not experienced any such difficulties. However, for the minority, the most commonly mentioned problem was being unable to, or discouraged from, participating in social events.
18. Those who said they had personally experienced a mental health problem were asked a set of questions about factors which they felt had assisted their recovery, and what they perceived to be indicators of recovery. Respondents said that the most important factors affecting their recovery were support from family and friends and medication. Asked if there were any factors which might have been helpful in their recovery, had they been available, respondents emphasised support from others, particularly counsellors and people with similar experience. Key signs of recovery were felt to include feeling better generally, feeling able to cope and taking charge of one's life again.
information sources and awareness of mental health issues
19. Respondents were asked which information sources had been important in forming their opinions about and attitudes towards mental health problems. The most common sources were personal contact or personal experience (mentioned by 57% of people in the sample). Television news and current affairs programmes were also cited as important by 44% of people. Young people aged 25-29 years were among those most likely to mention personal contact or experience. Meanwhile, men aged 35-54 years and women aged 55 years and over were most likely to mention television news and current affairs programmes as important sources of information.
20. Respondents were asked whether they felt that the media's portrayal of people with mental health problems was generally positive or negative. As in 2002, over two in five people (43%) said that media representation was more negative than positive, and 36% felt that there were both positive and negative aspects to media portrayal of mental health problems. Older people, particularly those aged 75 years and over, and those with lower educational or professional qualifications were most likely to say that the media portrayal of mental health problems was positive. Naturally, findings should be treated with some caution, as the survey did not investigate respondents' feelings of what 'positive' or 'negative' coverage might be.
21. The majority of respondents (72%) said they had either seen, read or heard a promotion about mental health in the last year. Promotions had most commonly been seen in adverts on television or at the cinema. Those who said they did not have any personal experience of mental health problems were less likely to have noticed adverts or promotions than those who said they had had such experience. Men (in general), women aged 55 years or more and respondents who rated their general health as poor, were also among those least likely to have noticed a campaign or promotion. In 2002, approximately 40% of people had noticed a recent promotion related to mental health. The question in the 2002 survey was less in-depth, but it appears that there is greater awareness of campaigns and other promotions than there was two years ago. There has been a good deal of campaign activity in Scotland since 2002, particularly work carried out as part of the integrated strategy operated by the national public awareness campaign 'see me,' but also by NHS Health Scotland as part of their national role in raising awareness and promoting mental health and well-being.
22. Several major policy initiatives and campaigns are currently underway in Scotland as part of the work of the National Programme. Respondents were read the titles of five of these and were asked whether they had heard of each of them
1. In addition to 'see me,' the initiatives are: 'Choose Life,' the national strategy and action plan to prevent suicide; the 'Breathing Space' telephone advice and referral service for people experiencing low mood or depression; Mental Health First Aid (MHFA) training; and the Scottish Recovery Network. Thirty-four percent said they had heard of the 'see me' campaign, while 26% said they had heard of 'Choose Life'. Fourteen percent said they were familiar with 'Breathing Space'. MHFA and the Scottish Recovery Network were, in effect, included as 'control' prompts: because MHFA was still at the piloting stage at the time of the interviews and the Recovery Network had not been officially launched, it was felt to be unlikely that members of the general public would have heard of either initiative. Eight per cent of respondents said they were aware of MHFA and the same percentage said they had heard of the Scottish Recovery Network.
attitudes towards mental health problems
23. Public attitudes to mental health problems are not straightforward. Responding to a battery of attitudinal statements, almost all study participants agreed that 'anyone can suffer from mental health problems' and that 'people with mental health problems should have the same rights as anyone else'. However, almost half of respondents (45%) agreed with the statement 'if I were suffering from mental health problems I wouldn't want anyone knowing about it' and a quarter of the sample agreed that 'the public should be better protected from people with mental health problems.' Approximately half of respondents (46%) were of the view that 'the majority of people with mental health problems recover'. This is a particularly difficult response to interpret in terms of respondents' understanding of mental ill health, as the 'experience of mental health problems' section of the questionnaire indicated that one in five respondents knew someone with a degenerative neurological disease.
24. Older respondents tended to hold more negative attitudes than people in younger age groups. People who said that they had no personal experience of mental health problems tended to be more negative than those who said they had either experienced a problem themselves or witnessed a problem in someone close to them. Analysis to assess the strengths of relationships between attitudes and socio-demographic and behavioural characteristics indicated that knowledge of the 'see me' campaign and/or 'Choose Life' were among the variables most strongly correlated with positive attitudes to mental health problems, as was obtaining information on mental health problems from personal contact, or health care professionals.
25. There appear to have been some significant shifts in attitudes towards mental health problems over the past couple of years. The proportions agreeing that 'if I were suffering from mental health problems I wouldn't want people knowing about it' and 'I would find it hard to talk to someone with mental health problems' have each fallen by 5 percentage points. The proportion of the sample agreeing that 'the public should be better protected from people with mental health problems' fell by 9 percentage points and, most strikingly, the proportion agreeing that 'people with mental health problems are often dangerous' fell by 17 percentage points. These shifts were not consistently more pronounced among a particular sub-group or groups of respondents but rather were evident to varying degrees across all groups.
26. Respondents tended to overestimate the proportion of people who would experience a mental health problem at some stage in their lives (the actual lifetime incidence of mental health problems is estimated to be around 25%). Although a significant proportion - 33% of the sample - gave a response of 30% or under, the mean percentage suggested was 48%. Nineteen percent of respondents thought that at least 70% of people would experience a mental health problem at some point in their lives. It is possible that people's estimates could be influenced by personal experience. For example, respondents living in areas with a high number of risk factors (such as unemployment, deprivation, high levels of crime) might be more likely to perceive the level of risk in general as being higher than is actually the case. Analysis by area lends credence to this interpretation. Respondents living in the most deprived areas of Scotland gave higher average estimates regarding the prevalence of mental ill health than those in the most affluent areas (51% versus 45%).
ATTITUDES TOWARDS specific SYMPTOMS OF MENTAL ILL HEALTH
27. Respondents were shown one of six scenarios which described symptoms associated with depression, schizophrenia or stress in a man (Robert) or woman (Shona). Then (without being told what condition was associated with the symptoms they had read) respondents were asked a series of questions about the person in the scenario and the symptoms he/she was displaying. Naturally, this meant that each scenario was considered by a relatively small sub-group of the full sample of respondents: this should be borne in mind when considering the findings.
28 The first question related to the perceived cause of the condition experienced by Robert/Shona. Respondents were most likely to mention stressful or disturbing events in Robert's/Shona's life, whichever of the three sets of symptoms they had been asked to consider. However, the majority also thought that the conditions could have been caused by a chemical imbalance in the brain, abuse suffered in childhood or physical illness. Those people who were shown the scenarios describing symptoms of schizophrenia were more likely than other respondents to mention a chemical imbalance in the brain, while those shown the scenarios relating to depression were more likely to mention physical illness. Robert's/Shona's own character or personality was mentioned by 56% of those shown the stress scenarios. Respondents in 2004 were significantly less likely than people in the 2002 sample to associate the symptoms of depression and stress with fate, Robert's/Shona's own personality or a genetic or inherited problem. This may indicate improved understanding of the causes of particular mental health problems, but it is important not to over-interpret the findings of two surveys.
29. Respondents were asked who would be the best people to help Robert/Shona with the problems he/she was experiencing. Family doctors, qualified counsellors and family members were seen as the best sources of help, regardless of the situation described in the scenario. However, half of those shown the scenario describing symptoms of schizophrenia thought that a psychiatrist would be helpful to Robert or Shona. Friends and neighbours were also seen as possible sources of help for the person in each of the scenarios: in particular where Shona, rather than Robert, was being considered.
30. Whichever scenario respondents were shown, the majority felt that the best place for Robert/Shona to live was in his/her own home with support from family members or friends. Findings from the 2002 survey were similar. However, a significant minority of both groups shown the scenarios depicting symptoms of schizophrenia, and the female version of the depression scenario, felt that Robert/Shona should live in special housing with professional support in the community.
31. Two thirds of people shown the schizophrenia scenarios and half of those shown the depression scenarios thought that Robert/Shona might harm him/herself. Of those shown the stress scenarios, one in five held this view. Asked to consider whether Robert/Shona would be likely to harm
others, very few respondents shown the stress or depression scenarios thought this was likely
. However, 40% of people considering the male version of the schizophrenia scenario and 32% who were shown the female version thought he/she might cause harm to others. The percentage of people agreeing that Robert/Shona might harm others was lower in 2004 than 2002 for each scenario except the male version depicting symptoms of schizophrenia.
32. Respondents were asked whether they would be prepared to interact with Robert/Shona in a number of different circumstances. The majority of those considering each scenario said that they would be willing to do the person a favour, move next door to the person, or spend an evening socialising with him/her. However, respondents were less willing to have Robert/Shona marry into their family and fewer than half considering each scenario said that they would allow him/her to provide childcare for someone in their family. In general terms, willingness to interact with Robert/Shona was highest among respondents who were shown the stress scenarios and lowest among those who were shown the schizophrenia scenarios. For each of the scenarios, respondents were generally more willing to interact with a female displaying the symptoms depicted than with a male showing the same symptoms. Between 2002 and 2004 there were significant increases in the percentage of respondents willing to interact with the people depicted in the depression scenarios in almost all of the circumstances described.
33. Finally, respondents were asked to say which condition the symptoms were
most likely to describe, from a list of possible conditions. The majority of those shown the depression scenarios were able to attribute the condition correctly (and few people opted for any other diagnosis). Respondents were less confident about recognising stress (half of those sampled opted for depression and nearly one in five felt that Robert/Shona was experiencing anxiety disorder). Approximately two in five who considered symptoms of schizophrenia picked schizophrenia as the condition but depression, personality disorder and nervous breakdown were also considered as possibilities. Findings are not directly comparable with 2002, since in that survey respondents were asked to say how likely they thought it was that the person in the scenario was experiencing stress, schizophrenia or depression (regardless of the scenario considered) and many people opted for all three.
KEY MESSAGES FROM THE RESEARCH
34. The sample for the survey is robust and representative of the Scottish adult population and, with the exception that its scope is limited to those living in private dwellings, there are no obvious caveats to be borne in mind when considering its findings, although it is not possible to tell whether there are attitudinal biases in the weighted sample of participants.
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35. Respondents' self-assessed general health ratings, GHQ12 score, and experience of mental ill-health were all strongly related to income, ease of managing on income and area deprivation. Those who had a low income, found it difficult to manage on their income or lived in a relatively deprived area were among those most likely to assess their own health as being poor, to have high GHQ12 scores, or to say that they have experienced a mental health problem. Such evidence reinforces the importance of health policies and initiatives which are both targeted and linked with broader social inclusion agendas.
36. There is a clear link between people's general health and their experience of mental health problems, with those who rated their general health as poor being more likely to say they had experienced a mental health problem or to have a high GHQ 12 score than those who rated their health as good. These findings point to the need for a holistic approach to tackling mental ill-health, which emphasises the role that a healthy lifestyle can play in promoting mental well-being, one of the key messages of the Executive's 'Healthy Living' initiative. Findings from the survey suggest that the public, and younger age groups in particular, may be receptive to such messages - around one in five of those aged 16-34 years identified exercise as a factor promoting positive mental health and around one in ten mentioned 'being healthy' as contributing to mental health.
37. Work is clearly a key factor influencing people's mental health. Whereas some respondents identified work as having a positive impact on their state of mind, others took the opposite view, suggesting its effects were primarily negative. The Executive's action plan
Healthy Working Lives (Scottish Executive 2004) signals a commitment to improving the health of working age people in Scotland and includes implementation of pilot projects on job retention for people who develop mental health problems. The findings from the present survey should help inform the plan and provide a source of baseline data for assessing its future progress.
38. A key aim of the National Programme is to promote wider understanding and awareness of factors that help to promote recovery from mental health problems. The survey suggested that medication and support from family and friends are particularly important sources of help for people who experience mental ill-health. However, it also identified a (perhaps unmet) demand for more social support in the form of counselling, therapy and help from others with similar experiences. These findings point to a need for more signposting of relevant sources of help and a greater emphasis on informal support networks.
39. There are signs that perceptions of mental ill-health have improved between 2002 and 2004. This was evident both in responses to the attitudinal battery and in reactions to the scenarios describing symptoms of particular mental health problems. While it is difficult to be certain what has brought about these changes, and too early to be confident that they represent a long-term trend, it seems likely that work of the National Programme and, in particular, the 'see me' campaign has helped to reduce some of the stigma surrounding mental ill-health. The fact that 72% of respondents said they were aware of recent promotional activity indicates that, at the very least, messages appear to be reaching the majority of the population.
40. Three years after the launch of the National Programme, the results from this survey provide a timely indication of public awareness of mental health issues, and attitudes towards, and experience of, mental ill-health and related issues. In a number of respects the findings indicate that current policy initiatives and campaigns may have gone some way towards improving understanding of mental ill-health and promoting positive shifts in attitudes towards people who experience mental health problems.
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