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CHAPTER 10: CONCLUSIONS
10.1 The overall aims of the third National Scottish Survey of Public Attitudes to Mental Health, Mental Wellbeing and Mental Health Problems were to examine the views and experiences of a representative sample of the adult Scottish population in relation to a spectrum of mental health-related issues and to compare findings with other relevant survey data, including the 2002 and 2004 waves of the study. Specific areas of investigation were: general health and lifestyle; mental wellbeing; experience of mental ill-health; attitudes towards mental ill-health; and awareness of campaigns, initiatives and promotional activity associated with the National Programme for Improving Mental Health and Wellbeing.
10.2 While the majority of respondents report good general health, people on lower incomes, people who experience difficulty managing financially and people who live in more deprived areas are the most likely to rate their general health as poor and to be more susceptible to mental ill-health. A recent study on the epidemiology of suicide show that those who have a low income and live in a deprived area are at heightened risk of dying by suicide, and that the gap between suicide rates in the highest and lowest social classes increases as socio-economic deprivation worsens (Platt et at, 2007). Findings from this ( Well?) study indicate that there may be an enhanced risk with regard to general and mental health, as well as suicide. It would be useful to examine these effects in more detail with a view to developing more targeted support services.
10.3 The series of correlations found in this study between aspects of social isolation and lifetime experience of mental ill-health support evidence from other research (eg Cattan et al., 2005; Miller, 1979, Ueno, 2005). However, it is not possible for a cross-sectional study such as this to establish causation. Longitudinal research would be required to investigate the direction of the relationship (ie to investigate whether social isolation is itself a cause of mental ill-health, or whether mental ill-health leads to social isolation).
10.4 Asked for their own perceptions of what might support their own sense of mental wellbeing, people were most likely to emphasise social and leisure activities with family or friends, and the weather. On the other hand, negative influences were considered to be pressures of work, low income and physical illness, along with, once again, the weather. People who reported relatively poor mental or physical health were less likely to feel they could control the circumstances that might affect their sense of mental wellbeing, suggesting that both groups are potentially vulnerable in this respect and require particular support. Other literature suggests that motivation and help-seeking is less common among those with lower levels of perceived control, potentially exacerbating this problem.
10.5 The percentage of respondents who say they have personal experience of mental health problems has remained stable at just over 25% through all three sweeps of the survey to date. However, it is encouraging to note that, of those who report such experience, the percentage who say they have experienced no difficulties in terms of other people's attitudes to their problems has risen by almost 10 percentage points since 2004. Interestingly, the proportion of respondents who had chosen to avoid a social event because of the way they thought people would react to their mental health problem is twice as high as the proportion who said they had actually been discouraged from participating in such events. This 'self-stigmatisation' and fear of rejection clearly have the potential to limit an individual's behaviour and, perhaps, link to a lower willingness to engage in social groups, as illustrated elsewhere in the study. Indeed, a recent study of patients diagnosed with schizophrenia found that self-stigmatisation undermined self-efficacy and empowerment which was associated with poorer quality of life and depression (Vauth et al, 2007).
10.6 There are some signs that there may be a generational change in people's recognition, or perhaps acknowledgment, of mental health problems. Younger groups are more likely to claim proxy experience of depression or a neurotic or stress-related disorder. However, while the great majority of those who had personal experience of a mental health problem had told someone, relatively few had told their employer, suggesting a fear of stigmatisation or discrimination at work. On a more positive note, there has been a steady decline in the proportion of those suffering mental health problems who report that they have suffered verbal abuse in public.
10.7 A message of hope from a professional, family member or friend at the time of diagnosis and treatment can be carried by the individual and act as a catalyst for getting better, or living well in the presence of their illness. The finding that positive messages of recovery are associated with better mental health and wellbeing reinforces findings from the recent narrative research (Brown & Kandirikirira, 2006).
10.8 Findings indicate a correlation between experience of mental health problems (proxy or personal) and higher recognition of a range of campaigns, initiatives and promotional activity, particularly initiatives focusing on recovery, suicide prevention training, the prevention of stigma and the 'Breathing Space' telephone advice line. On one level, these findings are intuitive: it might be expected that people with such experience will be more aware of relevant initiatives. It certainly appears that these initiatives are reaching those to whom they are likely to be most helpful. However, the engagement of people who do not have, or are unwilling to divulge, such experience is vital to increasing mental health literacy in Scotland.
10.9 People living in areas of multiple deprivation, where incidence of mental ill-health is higher, may be more likely to come into contact with those experiencing such problems. However, this study indicates that stigmatisation is no less common in such areas. This implies that exposure to mental health problems is not, by itself, enough to change attitudes and understanding. Although education and information campaigns in deprived areas may be of help, it is also likely that focussing more intensive support resources in such areas will be of considerable benefit.
10.10 There are clear indications from this survey that males exhibiting symptoms of mental ill-health are more likely to be avoided and viewed with suspicion. It also appears that men are more likely than women to avoid social contact with people exhibiting such symptoms. Perhaps both these themes can be explored and used in the modelling of future campaign activity. These findings also suggest that men may face particular issues in relation to social isolation when suffering from mental ill-health.
10.11 Further, the finding that those segments of the population which hold the most positive attitudes toward people with mental health problems also say they would be reluctant to disclose a mental health problem to others, provides a potent reminder of the prejudice still surrounding, or still perceived by respondents as surrounding, mental ill-health. People are unlikely to feel comfortable disclosing a problem until they are confident that this prejudice has been dealt with. It is well recognised that the relationship between attitudes and behaviour is complex, and these findings emphasise that complexity. They also have important implications for implementation of the Delivering for Mental Health strategy (Scottish Executive, 2006), in particular with respect to the 'responding better to depression, anxiety and stress' and the 'early detection and intervention in self-harm and suicide prevention' components. For these strategies to work, it is important that people feel able to talk about their symptoms.
10.12 The addition of WEMWBS to the survey reinforces the importance of strong social networks in promoting positive mental health. Similarly, the observed link between high WEMWBS scores and both low deprivation and satisfaction with neighbourhoods points towards the significance of the physical environment in promoting wellbeing.
10.13 Findings from the present study also suggest that further research on positive mental wellbeing would be valuable. For example, it would be useful to investigate the extent to which the WEMWBS is tapping other psychosocial concepts, such as resilience, to determine the extent to which they buffer the effects of adverse environmental influences on mental health.10.14 In addition to these specific points, the general significance of WEMWBS as a potential predictor of attitudes and behaviours underscores the importance of focusing on the promotion of positive mental wellbeing and not just engaging with mental distress. This is consistent with the current and planned direction of mental health policy in Scotland.
10.15 While the three surveys carried out to date have allowed the monitoring of trends in behaviour, experience and attitude across a range of mental health issues, we need to recognise that attitudes and behaviours are multi-factorial. To test the correlations that have been found, and to establish causation, would require a different, longitudinal research design.
10.16 The survey reinforces the message that a range of factors impact on mental health, wellbeing and attitudes and behaviours. The recent restructuring of the Scottish government, bringing together a range of areas under the portfolio of health and wellbeing, may offer new opportunities for effecting and sustaining changes in the mental health of Scotland's population.
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