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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7 ATTITUDES TOWARDS MENTAL HEALTH PROBLEMS

7.1 As noted in chapter 1, one of the main aims of the National Programme was to promote positive changes in attitudes towards people who experience mental health problems and illness. Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011 similarly outlines measures to address discrimination and stigma, including a strategy aimed specifically at tackling stigma within public services (Scottish Government 2009a). This chapter looks in detail at public perceptions of mental health problems and considers how these perceptions have evolved over the lifetime of the National Programme.

Attitudes towards mental health problems

7.2 As in the previous 'Well?' surveys, respondents were presented with a number of statements relating to mental health problems and asked to what extent they agreed or disagreed with each.

7.3 In many respects, the findings are encouraging. A large majority of respondents agreed that 'Anyone can suffer from a mental health problem' (93%) and that 'People with mental health problems should have the same rights as anyone else' (86%). Similarly, a majority disagreed with several of the more negatively worded statements namely: 'People with mental health problems are largely to blame for their own condition' (86%); 'I would find it hard to talk to someone with a mental health problem' (70%); and 'People with mental health problems are often dangerous' (57%).

7.4 On the other hand, roughly as many respondents agreed as disagreed that if they were suffering from a mental health problem, they wouldn't want people knowing about it (44% and 38% respectively), and whereas 41% of people disagreed that 'The public should be better protected from people with mental health problems', a significant minority (25%) agreed with this statement.

7.5 Views were similarly divided in respect of the statement, 'People are generally caring and sympathetic to people with mental health problems'. However, it is worth considering that what it means to agree or disagree with this statement is ambiguous and open to interpretation. On the one hand, agreement could be seen as a measure of society's general level of tolerance of people with mental health problems. This being the case, an increase in agreement with the statement over time would be a positive finding. On the other hand, agreement could also point towards a lack of awareness of society's stigmatising attitudes towards people with mental health problems. From this viewpoint, an increase in agreement over time would be a negative trend. In other words, there is a discussion to be had regarding the desirable direction of change for this measure.

7.6 There are few statistically significant differences between the 2008 results and those recorded in 2006. Specifically, and as figure 7.1 illustrates, there has been no change in the proportions of respondents agreeing and disagreeing with the statements: 'I would find it hard to talk to someone with a mental health problem'; 'People are generally caring and sympathetic to those with mental health problems'; 'People with mental health problems are often dangerous'; 'People with mental health problems should have the same rights as anyone else'; and 'People with mental health problems are largely to blame for their own condition'.

7.7 Responses to the statement, 'If I were suffering from a mental health problem, I wouldn't want people knowing about it', have also remained stable since 2006, despite a gradual downward trend in agreement between 2002 and 2006 (from 50% to 41%). This may suggest that the Scottish Government's work on tackling the stigma and discrimination associated with mental health problems might need to be considered in order to identify how further progress can be made.

Figure 7.1: Attitudes to mental health problems 2002-2008 (% agreeing)

Figure 7.1: Attitudes to mental health problems 2002-2008 (% agreeing)

7.8 Notwithstanding the trends in figure 7.1, there are a few differences between the 2008 and 2006 results. Most notably, the proportion of respondents agreeing with the statement, 'The public should be better protected from people with mental health problems', has fallen by 10 percentage points, to 25%, bringing it back to the level recorded in 2004. This fluctuation reinforces the view put forward in the previous 'Well?' report that the 2006 result may have been influenced by events which took place around the time of the survey and specifically the fact that there was considerable media interest in the issues of secure care violence and system failures (Figure 7.2).

7.9 However, there have also been slight decreases in the proportions of respondents agreeing with the statements 'Anyone can suffer from a mental health problem' (from 97% to 93%) and 'The majority of people with mental health problems recover' (from 46% to 42%). There are several possible reasons for these differences. First, it may be that the public has reached saturation point in terms of absorbing anti-stigma messages or that these messages are failing to reach some segments of the population. Second, the differences may reflect a decrease in advertising by "see me". Third, the changes may simply reflect natural, short term fluctuation in trends over time. Only when the survey has been repeated a number of times will it be possible to identify whether this latter hypothesis holds true.

Figure 7.2: Changing attitudes to mental health problems 2002-2008 (% agreeing)

Figure 7.2: Changing attitudes to mental health problems 2002-2008 (% agreeing)

7.10 It is worth noting that there has been no change in the intensity of agreement and disagreement with any of the attitude statements since 2006; that is, the proportions who strongly agree/disagree vis a vis the proportions who tend to agree/disagree have for the most part remained constant. While it is encouraging that there has been no hardening of negative attitudes, the lack of any shift towards strong agreement with the positively worded statements further reinforces the case for consideration of approaches to tacking stigma and discrimination.

7.11 Nonetheless, available evidence suggests that attitudes towards mental health problems in Scotland remain more positive than elsewhere in the UK. In the 2008 Health Promotion Agency Northern Ireland study, respondents were more likely than those in 'Well?' 2008 to agree that if they 'were experiencing a mental health problem, they wouldn't want other people knowing about it' (56% versus 44%), that 'The public should be better protected from people with mental health problems' (34% versus 25%), that 'People with mental health problems are often dangerous' (29% versus 19%) and that they 'would find it hard to talk to someone with mental health problems. Further they were less likely to agree that 'People with mental health problems should have the same right as anyone else' (77% versus 86%) (Health Promotion Agency 2008).

7.12 As was noted in the previous 'Well?' report, these differences may reflect the fact that, until 2006 there had not been a mental health anti-stigma and discrimination campaign in Northern Ireland equivalent to those that have run in Scotland since 2002 as part of the National Programme.

7.13 The 2009 Department of Health (DoH) Survey of Attitudes to Mental Illness also included a number of attitudinal statements, but none of these were the same as those included in the ' Well?' surveys so direct comparisons cannot be drawn. However, it is worth noting that 91% of respondents in the DoH study agreed that 'virtually anyone can become mentally ill', which is consistent with the 93% in 'Well?' 2008 agreeing that 'anyone can suffer from a mental health problem' ( TNS, 2009).

7.14 As in 2006, age emerged as one of the main correlates of attitudes towards mental health problems in 'Well?' 2008, with older people typically holding more negative views than younger groups. As table 7.1 shows, people aged 75 and over were more likely than younger groups to agree that: 'The public should be better protected from people with mental health problems'; 'People with mental health problems are often dangerous'; 'People with a mental health problem are largely to blame for their own condition'; and they would find it hard to talk to someone with mental health problems. These differences are likely to be a cohort effect.

7.15 Together with the youngest group of respondents (aged 16 to 24 years), people aged 75 and over were also among those most likely to agree that 'People are generally caring and sympathetic towards people with mental health problems' and to disagree that 'anyone can suffer from a mental health problem'.

Table 7.1: Attitudes towards mental health problems by age

% agreeing with each statement

16-24

25-34

35-44

45-54

55-59

60-64

65-74

75+

Base:

109

156

215

200

76

98

172

142

If I were suffering from a mental health problem, I wouldn't want people knowing about it

42

48

40

50

58

39

39

37

The public should be better protected from people with mental health problems

16

20

23

25

27

21

32

43

Anyone can suffer from a mental health problem

83

94

95

96

99

96

95

86

I would find it hard to talk to someone with mental health problems

16

14

10

11

17

12

22

22

People are generally caring and sympathetic to people with mental health problems

52

41

30

33

36

35

51

49

People with mental health problems are often dangerous

16

17

16

15

18

25

26

26

The majority of people with mental health problems recover

31

45

51

47

41

30

38

32

People with mental health problems should have the same rights as anyone else

87

84

87

86

86

90

84

83

People with mental health problems are largely to blame for their own condition

3

4

2

2

7

8

5

11

7.16 Attitudes were also closely associated with educational attainment. People with no qualifications were among those most likely to agree that:

  • 'The public should be better protected from people with mental health problems' (30% versus 20% of people with a degree or professional qualification)
  • 'People are generally caring and sympathetic towards people with mental health problems' (48% versus 30%)
  • they would 'find it hard to talk to someone with a mental health problem' (20% versus 13%)
  • 'People with mental health problem are often dangerous' (27% versus 12%)
  • 'People with mental health problems are largely to blame for their own condition' (9% versus 2%).

7.17 People with no qualifications were also less likely to agree that 'anyone can suffer from a mental health problem' (90% versus 97%).

7.18 However, it was people with the highest qualifications who were most likely to say that if they had a mental heath problem, they wouldn't want people knowing about it (46% versus 37% of those with no qualifications). As was suggested in the 2006 report, this may be because those with higher qualifications might feel their higher professional status would be threatened if it was revealed that they were experiencing a problem, or that they are less believing that society is supportive to those who experience such problems.

7.19 To some extent, differences by educational attainment are reflected in correlations between attitudes and area deprivation. People living in the most deprived areas (where educational attainment tends to be lower) were less likely than those in the least deprived areas to agree that 'Anyone can suffer from a mental health problem' (87% versus 95%), and more likely to agree that 'People are generally caring and sympathetic to people with mental health problems (45% versus 38%). Meanwhile, people in the least deprived areas were among those most likely to agree that if they were suffering from a mental health problem, they would not want people knowing about it (49% versus 36%).

7.20 There was further variation depending on whether or not respondents had any experience of a mental health problem. Compared to those with no experience of mental health problems, more people with personal or proxy experience of a problem disagreed that:

  • they would 'find it hard to talk to someone with mental health problems' (76% and 74% versus 68%)
  • 'People with mental health problems are largely to blame for their own condition' (91% and 89% versus 84%)
  • 'People are generally caring and sympathetic to people with mental health problems' (47% and 48% versus 40%)
  • and that 'People with mental health problems are often dangerous' (66% and 61% versus 55%).

7.21 People with personal (but not proxy) experience of a problem were also more likely than those with no experience to agree that 'The majority of people with mental health problems recover' (51% versus 40%) and that 'People with mental health problems should have the same rights as anyone else' (90% versus 84). At the same time, they were less likely to agree that 'The public should be better protected from people with mental health problems' (19% versus 26%).

7.22 In other words, it appears that experience of a problem, whether personal or proxy, tends to lead to increased awareness and tolerance of mental health problems but also a more negative view of the way society treats people with problems.

7.23 To some extent, these findings are reinforced by correlations between attitudes and mental health and wellbeing. People with a high GHQ12 score and those with below average mental wellbeing were more likely than average to agree that if they had a mental health problem, they wouldn't want people knowing about it (53% and 51%), and to disagree that 'People are generally caring and sympathetic to people with mental health problems' (41% and 53%).

7.24 In terms of other sub-group differences, there were associations between attitudes and gender: more men than women agreed that 'People are generally caring and sympathetic to people with mental health problems' (44% versus 36%), whereas more women agree that 'The majority of people with mental health problems recover' (45% versus 37%). In the 2006 survey, women were more likely than men to disagree with the statement, 'I would find it hard to talk to someone with a mental health problem', but no such difference was apparent in 2008.

7.25 All of the other correlations reported in this section are consistent with those observed over the previous surveys.

7.26 As in 2006, segmentation analysis was undertaken on the attitudinal data to further explore the links between attitudes and other variables. The resulting data served to reinforce the bivariate correlations discussed above (see Annex G for a fuller discussion of the analysis).

Perceived prevalence of mental health problems

7.27 In addition to promoting positive change in attitudes to mental health problems, a key aim of the National Programme was to improve the public's mental health literacy. To assess progress towards this aim, respondents in all four 'Well?' surveys have been asked to estimate how many people in Scotland, out of 100, will have a mental health problem at some point in their lives. Although the WHO (2001) and the Mental Health Foundation (2003) report that one in four people in the world are affected by mental or neurological disorders at some point in their lives, the estimates of lifetime prevalence vary (Bourden et al., 1992; Kessler et al., 1994, 2005). A recent estimate of the lifetime prevalence of an adult suffering from a disorder is 1 in 2, with 1 in 4 adults suffering from a disorder in any one year (Kessler et al., 2005).

7.28 In 'Well?' 2008, the mean estimate given was 49%, which is consistent with the results recorded in previous waves of the survey. Only 29% of respondents thought that the prevalence rate was below 30%; indeed, just under a quarter (22%) estimated it to be 70% or higher.

7.29 The mean estimate was higher than that recorded in other, similar surveys conducted elsewhere in the UK. For example, in the 2009 Department of Health Survey of Attitudes to Mental Illness a quarter of respondents estimated the prevalence rate at one in ten, with 41% thinking it was less than this. Thirteen per cent estimated the proportion was one in four and 8% thought it was higher than this ( TNS, 2009). The same question was included in the 2008 HPA Northern Ireland study and the figures recorded were similar: 29% estimated that one in ten people would experience a mental health problem at some point in their lives, 31% gave a lower figure than this, 6% estimated the figure at one in four and 7% gave a higher figure.

7.30 As was noted in the previous 'Well?' reports, it may be that the higher estimates in Scotland are a function of the various campaigns, initiatives and promotional activity that has taken place here, of which there have been few equivalents elsewhere in the UK. Equally, however, the estimates given in all three surveys are consistent with what would be expected if most respondents were simply guessing the prevalence rates and giving a 'middle-ground' answer as a safe option in the absence of greater knowledge. As already noted the mean estimate in the 'Well?' survey was 49%. Similarly, in the DoH and the Northern Irish studies, majorities of respondents gravitated around the mid-point of the list of possible response options.

7.31 In 'Well?' 2008, Mean estimates of the prevalence of mental health problems were higher than average among:

  • women (54% compared with 45% among men)
  • people aged 35 to 44 years (55% compared with 46% among people aged 16 to 24 years and 40% of those aged 75 and over),
  • those with personal or proxy experience of mental health problems (60%, and 53% compared with 48% of those with no such experience)
  • people with a high GHQ12 score (56% compared with 48% of those with a low score)
  • people with below average mental wellbeing (56% compared with 46% of those with above average mental wellbeing)

7.32 As in the 2006 survey, regression analysis was undertaken to explore further the relationship between respondents' estimates of the prevalence of mental health problems and their wider perceptions and experience of such problems. Specifically, the analysis sought to explore the relative influence of the following factors on respondents' prevalence estimates:

  • willingness to interact with someone displaying symptoms of a mental health problem 37
  • proxy experience of a mental health problem
  • proxy experience of any of 15 specific mental health problems 38
  • personal experience of a mental health problem
  • personal experience of any of 15 specific mental health problems

7.33 As figure 7.3 shows, six factors were found to correlate most strongly with respondents' estimates of the prevalence of mental health problems. These were: personal experience of a mental health problem; experience of panic attacks in someone close; willingness to interact with someone with symptoms of a mental health problem; experience of depression in someone close; experience of a mental health problem in someone close; and experience of stress in someone close. All of the correlations were positive - that is, they were associated with higher prevalence estimates. The percentages in figure 7.3 indicate the relative strength of each of the factors in terms of their relationship with prevalence estimates. So, for example, personal experience of a mental health problem was found to have twice the effect of any of the others factors in influencing prevalence estimates.

7.34 Each driver within the model has an unstandardised coefficient associated with it. The unstandardised coefficient represents the change in the predicted outcome (estimate of prevalence in percentage points) for every unit change in the driver. As most of the drivers are binary variables, a unit change is a change from zero to one and represents a change from absence to presence of the driver (or vice versa). Personal experience has the biggest effect of all the binary drivers. All other things being equal, someone who has had personal experience of mental ill-health will have a predicted outcome that is 12.19 percentage points higher than someone who has not. Applying the same logic, the following percentage point increases in predicted outcome can be found for the remaining drivers:

  • Experience of panic attacks in someone close (5.77)
  • Experience of depression in someone close (4.96)
  • Experience of a mental health problem in someone close (4.72)

Experience of panic attacks in someone close (5.57) 7.35 The willingness to interact measure is a composite score ranging from a minimum of 7 (very unwilling to interact for all seven QE5 components) to a maximum of 35 (very willing to interact for all seven QE5 components). For every single-point increase in this score, the predicted outcome increases by 0.46 percentage points.

7.36 While, the results in figure 7.3 are broadly similar to those obtained in 2006, the rank ordering of the factors is slightly different. The strongest three factors in 2006 were willingness to interact with someone with symptoms of a mental health problem, personal experience of a mental health problem and experience of a mental health problem in someone close, respectively. Further, these three factors were more equal in strength than was the case in 2008.

Figure 7.3: Perceived prevalence of mental health problems - regression analysis

Figure 7.3: Perceived prevalence of mental health problems - regression analysis

Sources of information on mental health problems

7.37 To identify factors shaping the attitudes and perceptions described in this chapter, respondents were asked what sources of information have been most important in forming their impressions of mental health problems. As in the 2006 survey, the most common responses were personal contact or experience and television news or current affairs programmes, mentioned by 56% and 45% respectively. The next most common were word of mouth (30%), health professionals (29%), national newspapers (26%), and work (28%). While this ranking is consistent with that recorded in 2006, the proportions of respondents mentioning word of mouth and health professions is slightly higher than in the previous survey (table 7.2)

7.38 Asked which single source of information had been most influential in forming their impressions of mental health problems, the majority of respondents mentioned either personal contact or experience, or television news and current affairs programmes, while around one in ten mentioned health professionals (9%). Again, these results are in line with those for 2006, notwithstanding a slight decrease in the proportion mentioning personal contact or experience (table 7.2).

Table 7.2: Sources influencing people's impressions of mental health problems

All sources

Single most important source

2002

2004

2006

2008

2002

2004

2006

2008

Base:

1,381

1,401

1,216

1,177

1,381

1,401

1,216

1,177

%

%

%

%

%

%

%

%

Personal contact/experience

38

57

59

57

21

39

41

37

TV news/current affairs programmes

51

44

45

45

18

15

16

15

National newspapers

34

26

29

26

8

4

4

4

Work

20

24

26

28

7

8

10

10

Word of mouth

29

32

25

30

5

7

5

5

Health professionals

33

27

25

29

17

8

7

9

Books/leaflets/magazines

28

24

21

24

5

3

3

2

Television soaps

14

15

16

15

2

2

3

3

Schools colleges

17

13

10

14

3

4

3

4

Local newspapers

16

13

10

12

2

1

1

1

Radio

10

10

9

10

1

1

1

1

Other TV

6

12

9

10

1

2

1

1

Internet

1

5

8

11

*

*

1

1

Other

1

1

3

*

1

*

1

1

None of these

6

3

2

2

6

4

3

2

Don't know

1

1

2

3

2

2

3

4

7.39 Mention of some of the sources in table 7.2 was correlated with age: people aged 25 to 54 years and 60 to 64 years were more likely than younger or older groups to mention personal contact or experience (67% of people aged 35 to 44 years and 66% of those aged 60 to 64 years, compared with 34% of those aged 16 to 24 years 48% of those aged 75 and over).

7.40 There were also correlations between sources mentioned and gender: men were more likely than women to mention national newspapers (30% versus 23%), while women - and particularly young women - were more likely to mention television soaps (22% of women aged 16 to 24 years compared with 15% of men). In 2006 women were also more likely than men to mention books, leaflets and magazines but this gender gap closed in 2008.

7.41 Further variation was apparent along socio-economic lines. Most notably, people in the least deprived areas were more likely than those in the most deprived areas to say they had formed their impressions about mental health problems from national newspapers (35% versus 14%), books, leaflets and magazines (30% versus 23%) and work (34% versus 18%). The latter difference in part reflects the fact that levels of employment are higher in less deprived areas.