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EXECUTIVE SUMMARY

Introduction

1. The National Programme for Improving Mental Health and Wellbeing was launched by the Scottish Executive in October 2001 with the aim of helping to improve the mental health and wellbeing of everyone living in Scotland and to improve the quality of life and social inclusion of people who experience mental health problems and illness. Since 2003, the main aims of the National Programme have been to raise awareness and promote mental health and wellbeing; eliminate stigma and discrimination; prevent suicide; and promote and support recovery from mental ill-health.

2. To help inform the work of the National Programme, as one part of the Executive's Health Improvement actions, the Scottish Executive commissioned the first National Scottish Survey of Public Attitudes to Mental Health, Mental Wellbeing and Mental Health Problems in 2002. The survey was designed to give a baseline set of data at the beginning of the National Programme's work and to be repeatable in order that it could be used to track progress and help influence future work towards the achievement of specific outcomes and objectives, namely:

• increased public awareness and understanding of mental health, mental wellbeing, mental health problems and mental illness
• improved public mental health 'literacy'
• positive changes in attitudes towards people who experience mental health problems and illness

3. The survey was run again in 2004 using a slightly altered version of the questionnaire to reflect progress in the National Programme's agenda.

4. Since the 2004 survey was conducted, there have been a number of developments in the mental health improvement policy arena in Scotland with the number of campaigns, initiatives and promotional activity associated with the mental health improvement agenda growing. Most notably:

• the Scottish Recovery Network ( SRN) was launched towards the end of 2004 with the aim of engaging communities across Scotland in debates and action on how best to promote and support recovery from long-term mental health problems
• during the same period, training for suicide intervention using ASIST (Applied Suicide Intervention Skills Training) and the 'Breathing Space' advice line for people experiencing low mood or depression were rolled out across Scotland
• 'see me…', the national anti-stigma campaign, developed a campaign aiming to reduce and eventually eliminate stigma and discrimination around mental health in the workplace
• Scotland's Mental Health First Aid training was launched nationally in 2005, following the evaluation of a pilot study
• 'HeadsUpScotland', the national project for children's and young people's mental health, was funded by the National Programme for two years from May 2004 to April 2006 and funding extended for 2006-08
• £8.4 million of additional funding was allocated to 'Choose Life', Scotland's strategy for suicide prevention and reduction, for the period 2006-2008
• 'Artfull', the initiative to promote the arts in improving mental health and wellbeing was launched in 2006
• Funds were invested in the Health Promoting Schools Unit to progress support and actions on the promotion of emotional and mental wellbeing within schools

5. Against this backdrop, the third National Scottish Survey of Public Attitudes to Mental Health, Mental Wellbeing and Mental Health Problems was commissioned in 2006. As in 2004, the questionnaire was refined for the 2006 survey to take account of the policy developments outlined above.

6. As in 2002 and 2004, the overall aims of the survey were to examine the views and experiences of a representative sample of the adult Scottish population (reflecting age, gender, income, location, race and ethnic diversity) in relation to a spectrum of mental health-related issues; and to compare findings with other relevant survey data. Specific objectives of the 2006 survey were to:

• Investigate people's perceptions of their own general health and lifestyle
• Explore people's understanding of the concepts of mental health and wellbeing, and their assessment of factors affecting their own mental health and wellbeing
• Investigate people's direct experience of mental health problems and recovery from mental health problems
• Investigate people's sources of information on mental health issues
• Explore people's awareness and understanding of promotional activity associated with mental health improvement work through the National Programme's main initiatives and areas of work
• Explore people's attitudes to mental health problems, including the stereotypes and myths surrounding mental illness
• Explore people's attitudes to those who experience specific symptoms of mental ill-health
• Compare findings with the 2002 and 2004 surveys and, as far as data are comparable, with findings from similar surveys (and from relevant components of broader surveys) carried out in Scotland, in other parts of the UK and internationally

7. The survey was conducted among a random sample of 1,216 Scottish adults between 16 October 2006 and 21 January 2007. All interviews were conducted face-to-face in respondents' homes.

General health and lifestyle

8. The National Programme works alongside other Scottish Executive policy areas including health, employment, education, equalities, social justice and social inclusion, recognising that many factors affect people's mental wellbeing. These correlations were explored in the survey and are reported in Chapter 4.

9. Most respondents rated their general health as good, with positive ratings most common among younger respondents, those in higher income brackets, those living in less deprived areas of the country, and those with a low mental ill-health score ² and good mental wellbeing ³.

10. The extent to which people are satisfied with the area in which they live can have a bearing on their mental health. The great majority of respondents said they were satisfied with their neighbourhood. Among the most satisfied groups were those who lived in the less deprived parts of the country, those living in rural areas and those with good mental wellbeing.

11. Having few close friends or relatives has been associated with a greater likelihood of experiencing symptoms of mental ill-health. The survey reveals that people with good mental wellbeing were more likely than those with poor mental wellbeing to see friends or relatives at least once a week.

12. Social interaction and engagement with local communities can also be important in enhancing mental well being and aiding recovery. The majority of respondents felt they had people they could turn to if they were ill in bed or in financial difficulties, and a substantial minority had worked as a volunteer.

13. The survey revealed a correlation between respondents' levels of social engagement (as defined by their informal support networks and their level of civic participation) and the number of people they felt they could turn to in a personal crisis - the more socially engaged had significantly more people they could turn to than the less socially engaged.

Mental health and wellbeing

14. Several measures were used in the survey to assess people's mental health and wellbeing in order to provide options for the analysis of the survey sample's attitudes to mental health, and these are reported in Chapter 5. Respondents completed the GHQ12, a validated screening instrument designed to gauge levels of possible psychiatric morbidity among the general population through their responses to 12 questions about their recent experience of anxiety, ability to concentrate, decision-making capacity, enjoyment of day-to-day activities, sleep disturbance etc. Consistent with 2004, the majority of respondents (83%) were classed as having no or few signs of possible psychiatric disorder (hereafter 'low mental ill-health scores'), while approximately a fifth were assessed as displaying signs of possible psychiatric disorder (hereafter 'high mental ill-health scores').

15. In addition to the GHQ12, the 2006 survey also included a new scale, the Warwick-Edinburgh Mental Well-being Scale ( WEMWBS), designed to measure positive mental wellbeing. The scale comprises 14 separate statements describing feelings related to mental wellbeing; respondents are asked to indicate how often they have felt such feelings over the last two weeks. WEMWBS is intended to complement standard scales which measure mental ill-health and mental health problems at a population level. This scale is currently undergoing a process of validation for use in Scotland.

16. WEMWBS was found to be normally distributed among the population, to correlate highly with the GHQ12 and to have a single underlying factor - that is, to tap one underlying concept, i.e. mental wellbeing.

17. On the basis of their responses to WEMWBS, 14% of respondents were classified as having 'good' mental wellbeing 73% as having 'average' mental wellbeing and 14% as having 'poor' mental wellbeing.

18. The factors most commonly identified by respondents as having a positive effect on emotions, mental health and wellbeing were spending time with family, leisure activities, hobbies and a social life and spending time with friends. Meanwhile, the factors considered to have a negative effect were weather, work or having too much work, not having a good income or enough money and physical illness. These results are broadly consistent with those from 2004.

19. Around two thirds (65%) of respondents felt they had a good deal or complete control over things that affect their mental health and wellbeing, compared with 8% who felt they had little or no control. Among those most likely to feel in control were respondents aged 16-24 years, those who found it easy to manage on their income and those with good mental wellbeing.

Experience of mental health problems

20. As well as using the GHQ and WEMWBS instruments in the survey, respondents were asked directly about their personal and proxy experience of mental ill-health. Around three in five respondents (61%) said that someone close to them had experienced a mental health problem. This is consistent with findings from the 2004 survey (62%). The most common conditions were depression, panic attacks and Alzheimer's disease/dementia. Younger people, and those who said they found it difficult to manage on their income were both more likely than others to say they knew someone with a mental health problem. Further, respondents with high mental ill-health scores were more likely to say they knew someone who had experienced mental ill-health.

21. Around a quarter of respondents (28%) said they had personally experienced a mental health problem. Again, this is in line with the figures recorded in 2002 (27%) and 2004 (26%). The specific mental health problems most commonly experienced by respondents were depression, panic attacks, severe stress and anxiety disorder. Among those most likely to have experienced a mental health problem were women, those who found it difficult to manage on their income, those with a high mental ill-health score and those with poor mental wellbeing.

22. The majority (86%) of respondents who had personally experienced a mental health problem had told someone (other than a doctor/health professional) about their problem. People were most likely to tell their family or friends but one in five had told their boss or manager at work or other colleagues at work.

23. 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. The proportion who said they had not experienced any difficulties has risen almost 10 percentage points since 2004 to 75%. That said, around one in ten had been discouraged from participating in social events, and one in twenty felt they had faced discrimination at work.

24. Respondents to the 2006 survey who had experienced a mental health problem were further asked if they had ever chosen to avoid a social event because of the way they thought people would react to their mental health problem. One in five (22%) said they had done so.

25. Those who said they had experienced a mental health problem were also asked a set of questions on recovery. (Recovery is defined, not as the absence of symptoms, but the means by which people regain control, hope and confidence in their lives.) The factors that respondents felt had been most important in supporting their recovery were support from family or friends, medication and developing their own coping strategies. The rank ordering of these factors is broadly consistent with the comparable 2004 findings, although the introduction of new items means that the absolute levels of response differs across the two surveys.

26. In terms of the factors which had most hindered their recovery, around one in five respondents said 'not acknowledging I had a problem', 'continuing to experience problems' and 'not understanding what was going on'.

27. When asked 'what does recovery mean to you?', around half said 'getting back to normal', while 38% said 'taking charge of my life again'. The next most common responses were 'feeling able to cope in general' and 'having a satisfying and fulfilling life'.

28. Respondents were asked to what extent they had received a positive or negative message about their recovery from professionals and people close to them. Most respondents had received positive messages from both groups; two thirds received a positive message from professionals while three quarters did so from people around them.

Attitudes towards mental ill-health

29. At the heart of the survey is a battery of attitudinal statements about mental health, reported in Chapter 7. For the most part, the attitudes expressed are fairly consistent with the 2004 survey. Thus, almost all (97%) respondents agreed that 'anyone can suffer from a mental health problem', 85% thought people with mental health problems should have the same rights as anyone else, 46% agreed that the majority of people with mental health problems recover and 40% agreed that 'people are generally caring and sympathetic to people with mental health problems'. Seventeen per cent agreed that 'I would find it hard to talk to someone with a mental health problem', 16% agreed with the statement that people with mental health problems are often dangerous and 4% said that 'people with mental health problems are largely to blame for their own condition'.

30. There have been some shifts in attitudes. The proportion of people agreeing with the statement, 'If I were suffering from mental health problems, I wouldn't want people knowing about it', has continued to decline, from 50% in 2002, to 45% in 2004 and 41% in 2006.

31. At the same time, however, the proportion of people agreeing that the public should be better protected from people with mental health problems (32%) has returned to the level recorded in 2002 (35%), following a decrease in 2004 (24%).

32. It was among older respondents, those with lower educational qualifications, those living in the most deprived areas of the country and those with no personal or proxy experience of mental ill-health that the most negative attitudes towards mental ill-health were found.

33. As in 2004, respondents tended to over-estimate the lifetime prevalence of mental ill-health (the actual prevalence rate is estimated to be around 25%). Seven in ten thought over 30% of people would experience a mental health problem at some point in their lives, and 20% thought the figure was over 70%. The mean estimate given was 47%.

34. Those who had personal or proxy experience of mental ill-health tended to give higher estimates than those with no such experience, and those with high mental ill-health scores gave higher estimates than those with low scores.

Attitudes towards specific symptoms of mental ill-health

35. One of the four key aims of the National Programme is to reduce the stigma associated with mental ill-health. To assess how the public feel they would react to people exhibiting a range of symptoms associated with mental ill-health, the survey presented respondents with one of six scenarios. Each described either a man (Robert) or a woman (Shona) displaying symptoms which were designed to relate to (but did not specifically name) depression, schizophrenia or stress. (The scenarios were randomly assigned to respondents.) Without being told the condition with which the symptoms were associated, respondents were asked a series of questions about the person in the scenario. Detailed analysis of this section of the survey can be found in Chapter 8. Additional analyses are included in Annex J.

36. The majority of respondents felt that the best place for Robert/Shona to live would be in their own home with support from family or friends, whatever the symptoms they were experiencing. However, a significant minority of those shown the schizophrenia scenarios thought Robert/Shona should live in special housing with professional support in the community. In terms of who would be the most appropriate person to help the person described in the scenario, the most common responses were a family doctor, a qualified counsellor or someone in the family. However, around half of respondents shown the schizophrenia scenarios mentioned a qualified counsellor.

37. The person in the scenario depicting symptoms of schizophrenia was judged to be more likely to harm him/herself than the person experiencing depression, and the person in the stress scenario was assessed as being least likely to self-harm. These findings are consistent with a recent British survey of non-fatal suicidal behaviour. Meltzer et al. (2002) reported that those individuals who had been diagnosed with schizophrenia were most likely to engage in self-harm (compared with other diagnostic categories), with approximately 50% having self-harmed at some time in their lives.

38. Few people thought Robert/Shona was likely to harm others but, again, it was the person experiencing symptoms of schizophrenia who was felt to be most likely to cause harm to others. Respondents who considered the male version of the scenario were more likely than those who considered the female version to feel the person depicted was likely to harm others. There have been few changes in these results over the three waves of the survey but among those shown the female version of the schizophrenia scenario, the percentage suggesting that Shona might harm others has fallen by 10 percentage points between 2004 and 2006.

39. For all of the scenarios, majorities said they would be willing to interact with Robert/Shona under a range of circumstances. These included doing them a favour, making friends with them, moving next door to and spending an evening socialising with them. However, smaller proportions were willing to have Robert/Shona marry into the family or to let Robert/Shona provide childcare for someone in their family.

40. Analyses were undertaken to explore to what extent willingness to interact with Robert/Shona varied depending on the specific scenario with which respondents were presented, respondents' own socio-demographic characteristics and survey wave (2002, 2004 or 2006). Willingness to interact with Robert/Shona was highest among those shown the stress scenarios, slightly lower among those shown the depression scenario and lower still among those shown the schizophrenia scenarios. For all of the scenarios, respondents were consistently more willing to interact with a female displaying the symptoms than with a male displaying the same symptoms.

41. In terms of respondent-based differences, females were more likely than males to say they would be willing to spend an evening socialising with Robert/Shona and to make friends with him/her. There was also an interaction between gender and income in relation to willingness to make friends with the person in the scenario. Males on a lower income expressed a higher level of willingness than those on a higher income. Among females the pattern was different: the lowest and highest income groups were more willing to make friends with Robert/Shona than those on middle-level income. Respondents' age was an important discriminator for two of the interaction measures: younger respondents were more willing to have Robert/Shona marry into the family, and to provide childcare for someone in the family.

42. The analysis revealed no consistent pattern of variation or trend across the three waves of the survey, although willingness to engage with the person in the scenario increased on several of the measures between 2002 and 2004. Between 2004 and 2006, willingness to interact with the people in the scenarios declined, in many cases falling back to the levels measured in 2002. This may be an indication that while responses to these kinds of questions might fluctuate, it is more difficult to discern a consistent trend, and that altering the public's behaviour in these areas is likely to be more challenging than eliciting more positive opinions and attitudes. It may also be that people today understand more about the symptoms of mental health problems, but do not yet feel equipped to deal with them.

43. Interpretation of the 'willingness to interact' battery of questions is also complicated by the possible impact of amendments made to the questionnaire in 2006 In 2004, the 'willingness to interact' questions were preceded by a question asking whether the person in the scenario should have the same rights, at work, for example, as others. This may have primed respondents to think in terms of equal rights and, possibly, encouraged a more socially acceptable response to the person in the scenario. In 2006 the wording of the rights question was changed (because it had not allowed meaningful analysis) to "How likely or unlikely do you think it is that Robert/Shona's freedoms and rights might have to be limited because of their illness?" When the ordering of the questionnaire was discussed by the Research Advisory Group, concerns were expressed that the new, more negative slant of this question might prepare respondents to give more negative answers to the 'willingness to interact' items. Accordingly, the rights question was asked after the 'willingness to interact' questions and, because of this, it may be that in 2006 we are seeing the most 'honest' response to these questions.

44. Around half of those shown the schizophrenia scenarios and a third of those shown the depression scenarios thought that Robert's/Shona's freedoms and rights might have to be limited because of their illness. The figure among those shown the stress scenarios was lower, at around one in five.

45. Consistent with findings from the 2004 survey, majorities of those shown the depression scenario were able to diagnose the symptoms correctly, but this was not the case with regard to the stress and schizophrenia scenarios. Almost half of those shown the stress scenarios thought that Robert/Shona was displaying symptoms of depression. Similarly, significant proportions of those shown the schizophrenia scenarios gave diagnoses of depression, nervous breakdown or personality disorder. Of course, respondents' assessments were not necessarily wrong. For example, the person in the schizophrenia scenario could very well be depressed and/or stressed. Respondents had to pick the most likely diagnosis, which did not allow them to include all that might be relevant. It is also an important point that, in general, people were able to identify the symptoms associated with schizophrenia as requiring more formal/higher levels of support, even if they were unable to make the diagnosis.

Sources of information on mental health problems and awareness of campaigns and initiatives

46. While not designed to probe in fine detail for recognition of sources of information, the survey did ask which sources people felt had been most important in forming their impressions about mental health problems. This, and people's recognition of the names of campaigns and other information sources is reported in Chapter 9. Most commonly mentioned were personal contact or experience (59%) and television news and current affairs (45%). Newspapers, work, word of mouth and health professionals were also mentioned by relatively large numbers of people.

47. Looking at respondents' single most important source of information on mental health problems, personal contact or experience and television news remain the top two responses, mentioned by 41% and 16%, but work becomes the third most important source (10%), ahead of national newspapers (4%).

48. Men, especially those aged 35 to 54 years, were among those most likely to mention television news and national newspapers, whereas women were more likely to mention books, leaflets, magazines and television soaps. Respondents with higher earnings were significantly more likely than those with lower earnings to mention media sources, work, health professionals, books, leaflets and magazines.

49. Four in five (79%) said they had seen, read or heard an advert or promotion about mental health or mental health problems - a higher proportion than in 2004 (72%). Over half had seen an advert or promotion in the cinema, while around a third mentioned leaflets in a doctor's or other type of surgery, and 20% mentioned newspaper adverts. The proportions mentioning television/cinema adverts and newspaper adverts have both increased significantly on 2004, by nine and five percentage points respectively.

50. In the 2004 survey, respondents were presented with a list of five specific mental health campaigns, initiatives and areas of promotional activity, then asked which of these they had heard of. The five were:

• 'Choose Life' - the national strategy and action plan to prevent suicide
• 'see me…' the national anti-stigma campaign
• the 'Breathing Space' telephone advice line for people experiencing low mood or depression
• Mental Health First Aid training
• the Scottish Recovery Network.

51. For the 2006 survey, the list was extended to include:

• ASIST (Applied Suicide Intervention Skills Training)
• 'ArtFull' - the initiative to promote the arts in improving mental health and wellbeing
• 'HeadsUpScotland', the national project for children and young people's mental health
• 'Doing Well By People with Depression', the programme which aims to improve access to appropriate services for people with depression
• 'Well' magazine, the bi-annual magazine on improving mental health and wellbeing in Scotland

52. Of all the campaigns, initiatives and promotional activity, 'see me…' and 'Choose Life', had the highest profile among respondents, with 37% and 32% respectively saying they had heard of these. While the figure for 'see me…' is in line with the comparable result for 2004 (34%), recognition of 'Choose Life' has increased significantly, by 6 percentage points.

53. Around a quarter of respondents had heard of 'Breathing Space' and 'Well' Magazine. The figure for Breathing Space is also significantly up on 2004 - by 10 percentage points (14%). Around one in five people said they had heard of 'HeadsUpScotland' and ASIST, while roughly half this proportion had heard of Mental Health First Aid, The Scottish Recovery Network, 'ArtFull' and 'Doing Well by People with Depression'. The figures for Mental Health First Aid and the Scottish Recovery Network have remained static since 2004.

54. Awareness of campaigns, initiatives and promotional activity was found to be correlated with more positive attitudes towards mental ill-health. Thus, the more campaigns, initiatives and promotional activity respondents were aware of, the more likely they were to agree that anyone can suffer from a mental health problem, that people with mental health problems should have the same rights as anyone else, and to disagree that the public should be better protected from people with mental health problems and that people with mental health problems are often dangerous. However, there was no correlation between awareness and the statement, 'If I were suffering from mental health problems I wouldn't want people knowing about it'. This confirms that stigma is fairly complex in nature, and that while campaigns, initiatives and promotional activities may be helping to change attitudes, there may still be some way to go before this is reflected in changing behaviour and deeper held values.

Key messages

55. 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 showed that people 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.

56. 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).

57. 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.

58. 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).

59. 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.

60. 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.

61. 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.

62. 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.

63. 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.

64. 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.65. 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.

66. 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.

67. 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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