Well? What Do You Think? (2008): The Fourth National Scottish Survey of Public Attitudes to Mental Wellbeing and Mental Health Problems

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6 EXPERIENCE OF MENTAL HEALTH PROBLEMS

6.1 This chapter focuses on respondents' personal experience of mental health problems, both through having experienced a mental health problem themselves and through the experiences of people close to them (experience by proxy). The chapter also considers the social consequences of mental health problems from the perspective of those with direct personal experience of problems and explores issues relating to recovery, including, what recovery means to people, factors that are seen to promote and hinder recovery, and recovery messages that people receive from professionals and those close to them.

Experience of mental health problems in someone close

6.2 Sixty-one per cent of respondents reported that someone close to them had 'ever experienced a mental health problem'. This figure, which has remained static since 2004, is lower than the 68% of respondents who, in a 2005 survey of public attitudes to mental health in Ireland (Mental Health Ireland, 2005), said that someone close to them ' has or has had some kind of mental illness'. Care should be taken when comparing these results given that the surveys were conducted three years apart and used different question wording (italicised) and different methodologies (the ' Well?' series of surveys are conducted face to face among a random sample of adults aged 16 and over, while the Irish study was conducted by telephone among a quota sample of adults aged 15 and over).

6.3 There was an association between proxy experience of a mental health problem and age: respondents aged 25 to 64 years were more likely than those aged 16 to 24 years, or 65 years and over to say that someone close to them had experienced a mental health problem. As in 2006, respondents aged 75 years and over were less likely than all other age groups to say that someone close to them had experienced a problem.

6.4 In the 2006 ' Well?' survey, correlations were observed between proxy experience of a problem and finding it difficult to manage financially (71% of those who found it difficult to manage said someone close to them have experienced a problem compared with 58% of those who found it easy to manage). This difference was not apparent in 2008 (the corresponding figures were 62% and 63% respectively).

6.5 However, there were associations between proxy experience and income: respondents with a household income of £26,000 or more were more likely than average to have proxy experience of a mental health problem (for example, 75% of those earning between £26,000 and £36,399 compared to 52% of those earning less than £5,200 per year). These differences stand in contrast to the finding, reported below, that lower income groups were more likely than higher income groups to report personal experience of a mental health problem. Reasons for this paradox are unclear but it may be that higher income groups are more likely to discuss their mental health problems with people close to them.

6.6 Proxy experience of problems was also associated with having a high GHQ12 score (76% of those with a high score reported proxy experience compared with 59% of those with a low score) and below average mental wellbeing (73% versus 49% of those with above average mental wellbeing). This presents another paradox: if lower income groups, who have higher GHQ12 scores, have less proxy experience, but at the same time people with higher GHQ12 are more likely to report proxy experience, why are those with a lower income (who tend to have higher GHQ12 scores) claiming less proxy experience? Again, it may be that lower income groups are more reticent about revealing their mental health problem to those close to them but there may be other reasons too: while we can observe correlations between views expressed and other factors, it is not possible to draw firm conclusions about causality.

6.7 There were further associations between proxy experience of a mental health problem and educational qualifications: 76% of respondents with degree-level qualifications said someone they knew had experienced a mental health problem, compared with 51% of those without any qualifications.

6.8 Respondents were presented with a list of specific mental health problems and asked if anyone close to them had ever experienced any of these. The conditions that respondents most commonly said someone close to them had experienced were depression (45%), panic attacks (26%) and Alzheimer's disease or dementia (22%), followed by post-natal depression (16%), severe stress (14%), nervous breakdown (14%), and anxiety disorder (13%). Panic attacks, anxiety disorder and severe stress, along with excessive compulsive disorders and phobias (mentioned by 8% and 6% respectively) can be combined under the heading of anxiety and stress-related disorders. A total of 38% of respondents reported proxy experience of such disorders. These results are broadly consistent with the 2006 findings.

6.9 Proxy experience of particular problems was correlated with socio-economic measures. Most notably people who found it difficult to manage on their income were more likely than those who found it easy to manage to report proxy experience of manic depression (16% versus 10%), a nervous disorder (17% versus 11%), panic attacks (35% versus 22%), and self-harm (17% versus 8%). Meanwhile, people living in the least deprived areas of the country were more likely than those in the most deprived areas to report proxy experience of Alzheimer's disease or dementia (27% versus 16%).

6.10 There were also associations between proxy experience of specific problems and mental health and wellbeing: respondents with a high GHQ12 score were more likely than those with a low score to report proxy experience of all the listed conditions apart from Alzheimer's disease or dementia, personality disorder, schizophrenia and self-harm. Meanwhile, those with below average mental wellbeing were more likely than those with above average mental wellbeing to report proxy experience of:

  • depression (52% versus 37% of those with above average mental wellbeing)
  • manic depression (19% versus 7%)
  • nervous breakdown (20% versus 8%)
  • self-harm (14% versus 6%)
  • post traumatic stress disorder (9% versus 4%).

Personal experience of mental health problems

6.11 As in the previous 'Well?' surveys, around a quarter (26%) of respondents said they had 'personally experienced a mental health problem'. This is considerably higher than the 5% of respondents to a 2009 Department of Health Survey of Attitudes to Mental Illness who said that they had personally experienced ' some kind of mental illness' ( TNS, 2009). It is also higher than the 14% of respondents in the 2008 Health Promotion Agency ( HPA) Northern Ireland survey who said 'I have experienced mental health issues myself' and the 9% in the 2005 Mental Health Ireland Survey who said they 'have personally suffered from mental illness'. As in the case of proxy experience, however, these differences are in part likely to reflect the different question wording used in the surveys (italicised) and the fact that each survey was conducted in different years using different methodologies (like the 'Well?' surveys the DoH study and the HPA study were conducted face to face but households were selected for participation using quota rather than random pre-selected sampling. The Mental Health Ireland study was conducted by telephone and also among a quota sample).

6.12 In 'Well?' 2008, personal experience of mental health problems was correlated with:

  • gender - 31% of women had experienced a problem compared with 20% of men
  • age - 37% of respondents aged 35 to 44 years had experienced a problem compared to 12% of those aged 16 to 24 years and 12% of those aged over 75 years
  • having a low income - 37% of those earning less than £5,200 per year compared to 23% of those earning £36,400 or more
  • finding it difficult to manage financially - 42% versus 22% of those who found it easy to manage
  • living in the most deprived areas of the country - 40% versus 19% of those in the least deprived areas
  • having bad or very bad (self-assessed) general health - 48% versus 22% of those with good general health)
  • having a high GHQ12 score - 47% versus 21% of those with a low score
  • having below average mental wellbeing - 53% versus 13% of those with above average mental wellbeing

6.13 Where comparable, these differences are in line with findings from the 2009 DoH survey.

6.14 The specific mental health problems most commonly experienced by respondents were depression (17%), panic attacks (6%), anxiety disorder (4%), severe stress and post-natal depression (each 3%). If all of the anxiety and stress-related disorders are grouped together, as in the case of proxy experience, a total of 11% had personal experience of such a disorder. Again, these findings are broadly consistent with the 2006 results.

6.15 Experience of depression and panic attacks was most common among respondents with no qualifications (22% compared to 15% of respondents with degree level qualifications), those living in the most deprived areas (24% compared to 11% of those living in the least deprived areas) and those who said they found it difficult to manage on their income (33% compared to 13% of those who said they found it easy to manage). The later group of respondents were also among those most likely to have experienced severe stress (7% compared to 3% of those who found it easy to manage).

6.16 Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011 acknowledges the higher prevalence of mental health problems among economically disadvantaged groups and indeed outlines action to undertake work focused specifically on addressing depression, stress and anxiety among deprived communities.

Telling others about mental health problems

6.17 In the 2006 and 2008 surveys, respondents who said they had personally experienced a mental health problem were asked if they had told anyone (other than their doctor or other health professionals) about it. In 2008, 88% said that they had done so. The majority (85%) said they had told family or friends while around one in five said they had told their boss or manager at work or other colleagues (20% and 18% respectively). Smaller proportions had told people they don't know well (9%) or a tutor or member of staff at college or university (6%). Twelve per cent said they had not told anyone about their mental health problem. As illustrated in figure 6.1, the findings are very much in line with the 'Well?' 2006 results.

6.18 That most respondents had chosen not to disclose their mental health problems at work is consistent with findings from surveys conducted elsewhere in the UK. For example, a survey conducted on behalf of DoH and The Mental Health Foundation found that 52% of respondents concealed their mental health problems for fear of losing their job (DoH, 2001). Similarly, in a 2005 survey exploring mental health and employment in Ireland, two-thirds of respondents said they would feel unable to disclose their mental health problems at a job interview and four in ten said they had not disclosed their mental health problems to anyone in their workplace (Workway, 2005).

Figure 6.1 Disclosure of mental health problems

Figure 6.1 Disclosure of mental health problems

6.19 While small base sizes preclude full sub-group analysis of the findings, a correlation was evident between disclosure of mental health problems and gender: women were more likely than men to say they had told family or friends about their mental health problem (91% versus 75%) while men were more likely than women to say they had not told anyone (22% versus 7%).

The social impact of mental health problems

6.20 Respondents who said they had experienced a mental health problem were asked about the social impact of their condition and specifically, about any difficulties they had experienced in terms of other people's attitudes towards their problem. As shown in table 6.1, 77% of respondents said they had not experienced any such difficulties. This figure has remained stable since 2006, despite an increase of over 10 percentage points between 2004 and 2006 (from 64% to 75%).

6.21 Among the minority who had experienced difficulties in terms of other people's attitudes, 10% reported being discouraged from participating in social events, 5% said they have been discouraged from taking part in local community life and 4% said they had refused a job or been discriminated against at work.

6.22 While these figures have remained fairly static since 2006, the proportion of respondents who said they have been physically abused in public (3%) has returned to the level recorded in 2004, suggesting that the 2006 result (less than half a per cent) reflected natural, short term fluctuation in the findings.

Table 6.1: Social impact of mental health problems, 2002-2008

% who have experienced each

2002

2004

2006

2008

Base: All who have personally experienced a mental health problem

440

377

384

359

%

%

%

%

Discouraged from participating in social events

12

15

11

10

Experienced discrimination at work

7

6

5

4

Been refused a job

6

4

5

4

Verbally abused within the family

7

6

4

3

Discouraged from taking part in community life

4

6

4

5

Discouraged from going on holiday

3

4

4

2

Been overlooked/refused for promotion

4

5

3

3

Physically abused within the family

4

4

2

3

Verbally abused in public

8

5

2

3

Discouraged from participating in children's school based activities

1

2

2

2

Physically abused in public

3

2

*

3

Graffiti or rubbish targeted at the home

1

1

1

1

Other

2

2

2

*

None of these

68

64

75

77

Don't know

1

*

*

1

6.23 Data from the 2006 and 2008 surveys was combined to allow sub-group analysis of the findings. The analysis found that experience of stigma was correlated with gender, socio-demographic characteristics and mental health. Specifically:

  • men were more likely than women to say they had not experienced any difficulties (80% versus 70%). However, they were also more likely to say they had been discouraged from participating in social events (15% versus 8% of females).
  • respondents living in the most deprived areas were among those most likely to say they had been discouraged from participating in social events (17% versus 6% of those living in the least deprived areas) and community life (9% versus 1%)
  • respondents who found it difficult to manage on their income were more likely than those who found it easy to manage to say they had been discouraged from participating in social events (17% versus 7%), children's school based activities (4% versus 1%), and community life (11% versus 2%). They were also more likely to say they had been refused a job (8% versus 3%) and been physically abused within their family (5% versus 1%).
  • respondents with a high GHQ12 score were also particularly likely to say they had been discouraged from participating in social events (15% versus 8% of those with a low score) and community life (8% versus 3%). They were also among those most likely to report experience of verbal abuse in public (6% versus 2%), physical abuse within their family (4% versus 1%), and discrimination within their workplace (8% versus 3%).

6.24 Respondents who said they had experienced a mental health problem were also 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. As in 2006, around a quarter of respondents (24%) said they had done so. This figure is significantly higher than the proportion who said they had actually been discouraged from participating in a social event (10%) which suggests that self-stigmatisation is a major issue in this respect: it is the anticipation of failure or rejection which limits, in part, an individual's behaviour.

Recovery from mental health problems

6.25 During the first phase of the National Programme for Improving Mental Health and Wellbeing (2003-2006), there was a focus on establishing national and local delivery agencies to support the recovery of people experiencing mental health problems. The Scottish Recovery Network ( SRN) was launched in late 2004 with a remit to raise awareness that people can and do recover from long term and serious mental health problems, identify what recovery might mean for people, and build understanding of what helps people recover and stay well.

6.26 The Scottish Government has announced its intention to continue funding the SRN to promote recovery-based service delivery and self-directed approaches to recovery until 2011 (Scottish Government 2009a). An evaluation is planned to commence in 2009-10. To inform work in this area, and to help measure progress to date, respondents to the 2004, 2006 and 2008 ' Well?' surveys who had experienced a mental health problem, were asked a suite of questions about their own recovery. In 2006 and 2008, the focus of the questions was on identifying factors that support and hinder recovery, establishing what recovery means to people, and identifying the recovery messages that people receive from those around them and from health professionals.

Factors that promote and hinder recovery

6.27 In terms of factors that respondents felt had supported their recovery, the top responses were 'support from family or friends' (62%), 'medication' (39%), 'having belief in myself' (31%) and 'developing my own coping strategies' (24%), respectively. The next most common answers were 'other forms of treatment and therapy' (19%), 'support from people with a similar experience' (13%), 'having something worthwhile to do during the day' (13%) and 'having others believe in me' (12%). The only statistically significant difference between these results and those from 2006 is a decrease in the proportion of people mentioning 'other' forms of treatment or therapy (table 6.2).

Table 6.2: Factors important in supporting recovery

2004

2006

2008

Base: All who have personally experienced a mental health problem

377

384

359

%

%

%

Support from family or friends

76

56

62

Medication

38

35

39

Having belief in myself

n/a

27

31

Developing my own coping strategies

n/a

30

24

Other forms of treatment/therapy ( e.g. psychology, counselling, alternative treatments, support groups)

29

30

19

Support from people with a similar experience

14

11

13

Having something worthwhile to do during the day ( e.g. work, volunteering, education, hobbies, etc.)

21

11

13

Having others believe in me

n/a

12

12

Support from colleagues/work

18

8

12

Finding out more about mental health ( e.g. through support groups, leaflets, web information etc.)

6

8

8

Having a chance to contribute and be valued

n/a

2

5

Other

3

6

-

I don't believe myself to be in recovery

2

*

2

None of these

4

3

3

Don't know

*

*

*

6.28 Sub-group analysis of the combined data for the 2006 and 2008 surveys 35 revealed that women, (41% versus 31% of men), people with no qualifications (58% versus 26% of those with a degree or professional qualification), and those earning £5,200 or less (53% versus 24% of those earning £36,400 or more) were particularly likely to cite medication as an important influence on their recovery.

6.29 Respondents aged 35 to 44 years were more likely than average to cite other forms of treatment or therapy (28% versus 20% overall), as were respondents with a degree or professional qualification (26% versus 12% overall).

6.30 Respondents living in the most deprived areas were more likely than respondents in the least deprived areas to cite support from people with a similar experience (18% versus 8% of those in the least deprived areas) and finding out more about mental health (13% versus 5% of those in the least deprived areas). Respondents living in the least deprived areas, on the other hand, were more likely to cite development of their own coping strategies (40% versus 25% of those in the most deprived areas) and other forms of treatment or therapy (25% versus 14% of those in the most deprived areas).

6.31 Factor analysis was conducted to identify related influences on recovery. The analysis revealed that 'external' factors such as support from family or friends, had a more important bearing on recovery than 'internal' factors such as having self-belief (taking into account the fact that there are more external than internal factors listed in the question). On the whole, however, the factors did not group together in any strong or meaningful way. This would suggest that recovery is typically influenced by a range of different factors and that these will vary unpredictably from person to person.

6.32 Turning to factors that have hindered people's recovery from mental health problems, the most common responses were 'continuing to experience symptoms' (19%), 'not understanding what was going on' (19%) and 'not acknowledging I had a problem' (17%) (table 6.3). Reinforcing findings reported above, stigma was also clearly an issue for some people, with 15% mentioning 'not being able to tell people about my mental health problem' and 11% mentioning 'negative attitudes of people around me'. Just over a third (34%) said that none of the factors listed in the question had hindered their recovery (table 6.3). Given than this figure is relatively high, it may be that there are factors, other those listed in the question, which hinder recovery. Or, it may simply be the case that significant proportions of people cannot 'pin down' what, if anything, has prevented them from getting better. All of the results for this question are consistent with those for 2006.

Table 6.3: Factors hindering recovery

2006

2008

Base: All who have personally experienced a mental health problem

384

359

%

%

Continuing to experience symptoms

17

19

Not understanding what was going on

17

19

Not acknowledging I had a problem

19

17

Not feeling able to tell people about my mental health problem

12

15

Not getting the right medication

6

12

Negative attitudes of people around me

13

11

Not being able to access appropriate services or treatment

4

7

Lack of support or understanding from family or friends

9

6

Lack of support or understanding from colleagues/work

5

6

Lack of access to employment, education or training opportunities

4

5

Other

6

*

None of these

34

34

Don't know

2

4

6.33 Again, there were a number of sub-group differences in the findings. Not getting the right medication was particularly likely to be cited by respondents who:

  • found it difficult to manage on their income (14% versus 5% of those who found it easy to manage)
  • earned less than £5,200 a year (25% versus 7% of those earning between £26,000 and £36,399)
  • rated their health as bad or very bad (16% versus 8% of those rating their health as good or very good)
  • had a high GHQ12 score (14% versus 7% of those with a low score).

6.34 Continuation of symptoms was particularly likely to be cited by respondents:

  • living in the most deprived areas (23% versus 12% of respondents living in the least deprived areas)
  • with a high GHQ12 score (28% versus 13% of those with a low score)

6.35 Negative attitudes were most commonly cited by respondents:

  • with a high GHQ12 score (15% versus 8% of those with a low score)
  • living in the most deprived areas (16% versus 7% of those living in the least deprived areas)
  • earning less than £5,200 a year (30% versus 12% overall).

6.36 Finally, lack of support from family or friends was particularly an issue for respondents earning less than £5,200 per annum (18% versus 4% of those earning £36,400 or more).

Conceptions of recovery

6.37 The survey found that, for the majority of people who have had a mental health problem, recovery means simply 'getting back to normal'. However, for around a quarter, it also means 'feeling able to cope in general' and 'taking charge of my life again'. Comparatively few respondents equated recovery with having fewer symptoms or no longer needing treatment. This is consistent with the conception of recovery promoted by the SRN, which, among other things, emphasises that people can live satisfying and fulfilling lives in the presence or absence of ongoing symptoms 36.

6.38 For the most part, and as table 6.4 illustrates, the results are in line with those for 2006, but there had been a decrease in the proportion of respondents equating recovery with taking charge of their life again.

Table 6.4: Conceptions of recovery

2006

2008

Base: All who have personally experienced a mental health problem

384

359

%

%

Getting back to normal

49

53

Feeling able to cope in general

32

27

Taking charge of my life again

38

24

Having a satisfying and fulfilling life

20

18

Getting back to work

6

10

Fewer symptoms

9

8

Getting involved in activities I enjoy

8

6

Feeling more able to socialise

7

6

No longer needing treatment or services (including medication)

5

6

To feel positive/happy/confident again

-

1

Getting more sleep

6

1

Don't know

2

3

6.39 Sub-group analysis of the combined data for the 2006 and 2008 surveys found that:

  • respondents aged 75 or over were more likely than average to cite getting involved in activities they enjoy (20% versus 7% overall)
  • respondents aged 60 to 64 years old were more likely than average to cite feeling positive/happy/confident again (11% versus 4% overall)
  • respondents with a high GHQ12 score were more likely than those with a low score to cite feeling able to cope in general (33% versus 23%)
  • respondents with above average mental wellbeing were more likely than average to cite fewer symptoms (16% versus 9% overall)
  • respondents who found it difficult to manage on their income and those without any qualifications were particularly likely to cite getting back to work (12% versus 5% of those who found it easy to manage and 15% versus 8% of those with qualifications, respectively)
  • respondents living in the most deprived areas were more likely than those living in the least deprived areas to cite getting back to normal (63% versus 45%).

Messages of recovery from family, friends and professionals

6.40 Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011 includes a strategy to tackle stigma within Scotland's public services (Scottish Government, 2009a). Findings from the survey suggest some progress may already be underway in this area. As figure 6.5 shows, around three-quarters of those who had had a mental health problem said that they had received a positive message of recovery from the professionals with whom they came into contact; a higher proportion than in 2006 (66%).

Figure 6.5: Message of recovery from professionals

Figure 6.5: Message of recovery from professionals

6.41 As figure 6.6 illustrates, a majority (79%) had also received a positive message of recovery from the people around them (friends, family, colleagues, carers etc.), while 15% had received a negative message. These results are unchanged on 2006.

Figure 6.6: Message of recovery from friends, family, colleagues, carers etc.

Figure 6.6: Message of recovery from friends, family, colleagues, carers etc.

6.42 Sub-group analysis of the combined data for the 2006 and 2008 surveys revealed that women were more likely than men to say that they had received a positive recovery message from professionals (75% versus 61%), and from people around them (80% versus 72%).

6.43 There was also some variation by mental health; respondents with a low GHQ12 score were more likely than those with a high score to say they had received a positive message from professionals (74% versus 62%) and from people around them (83% versus 72%).

6.44 As in 2006, analyses were undertaken to identify whether there was a relationship between the recovery messages people had received and their mental health and wellbeing (as measured using the GHQ12 and WEMWBS). Once again, the results show that people who had received a positive message from professionals were more likely than those who had not to have above average mental wellbeing - although they were no more likely to have a low GHQ12 score. Meanwhile, people who had received a positive message of recovery from family and friends were more likely than those who had not to have above average mental wellbeing and a low GHQ12 score.

6.45 These results are consistent with findings from narrative research carried out by SRN which indicate that being given optimistic messages of recovery potential (from friends and family, professionals, carers, peers) had a positive impact on individuals and "gave them the emotional strength to fuel their own recovery journeys" (Brown & Kandirikirira 2008).