The Third National Scottish Survey of Public Attitudes to Mental Health, Mental Wellbeing and M

Well? What Do You Think?(2006)

The Third National Scottish Survey ofPublic Attitudes to Mental Health, MentalWell-being and Mental Health Problems

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Well?

WhatDo

YouThink?(2006)

WELL? WHAT DO YOU THINK? (2006) THE THIRD NATIONAL SCOTTISH SURVEY OF

PUBLIC ATTITUDES TO MENTAL HEALTH, MENTAL WELLBEING AND MENTAL HEALTH

PROBLEMS Simon Braunholtz, Sara Davidson and Katherine Myant, Ipsos MORI and

Dr Rory O’Connor, University of Stirling

Scottish Government Social Research 2007

TABLE OF CONTENTS PAGE ACKNOWLEDGEMENTS 1 GLOSSARY OF TERMS 2 EXECUTIVE SUMMARY 4 CHAPTER 1: INTRODUCTION 16 CHAPTER 2: RESEARCH METHODOLOGY AND ANALYSIS 20 CHAPTER 3: DEMOGRAPHIC PROFILE OF RESPONDENTS 26 CHAPTER 4: GENERAL HEALTH AND LIFESTYLE 33 CHAPTER 5: MENTAL HEALTH AND WELLBEING 40 CHAPTER 6: EXPERIENCE OF MENTAL HEALTH PROBLEMS 54 CHAPTER 7: ATTITUDES TOWARDS MENTAL HEALTH PROBLEMS 69 CHAPTER 8: ATTITUDES TOWARDS SPECIFIC SYMPTONS OF MENTAL ILL-HEALTH

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CHAPTER 9: SOURCES OF INFORMATION ON MENTAL HEALTH PROBLEMS AND AWARENESS OF CAMPAIGNS, INITIATIVES AND PROMOTIONAL ACTIVITY

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CHAPTER 10: CONCLUSIONS 104 REFERENCES 107 ANNEX A: ADVANCE LETTER 110 ANNEX B: SURVEY ADMINISTRATION 111 ANNEX C: CONTACT SHEET 114 ANNEX D: QUESTIONNAIRE CHANGES FOR THE 2006 SURVEY 118 ANNEX E: QUESTIONNAIRE 120 ANNEX F: MULTIVARIATE ANALYSIS TECHNIQUES 143 ANNEX G: STATISTICAL SIGNIFICANCE AND RELIABILITY 144 ANNEX H: OMISSION OF GHQ12 QUESTIONS FROM SURVEY SCRIPT FOR PART OF THE FIELDWORK PERIOD

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ANNEX I: ADDITIONAL MULTIVARIATE ANALYSES UNDERTAKEN 152 ANNEX J: MENTAL HEALTH SCENARIOS – QUESTION BY QUESTION ANALYSIS

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LIST OF TABLES/CHARTS PAGE CHAPTER 2: RESEARCH METHODOLOGY AND ANALYSIS 20 TABLE 2.1: SAMPLE PROFILE 23 CHAPTER 3: DEMOGRAPHIC PROFILE OF RESPONDENTS 26 TABLE 3.1: AGE AND SEX 26 TABLE 3.2: ETHNICITY 27 TABLE 3.3: ANNUAL HOUSEHOLD INCOME 28 TABLE 3.4: EASE OF MANAGING ON HOUSEHOLD INCOME 29 TABLE 3.5: WORKING STATUS 30 TABLE 3.6: QUALIFICATONS 31 TABLE 3.7: URBAN/RURAL COMPOSITION 32 CHAPTER 4: GENERAL HEALTH AND LIFESTYLE 33 FIGURE 4.1: RATINGS OF GENERAL HEALTH 33 TABLE 4.1: RATINGS OF GENERAL HEALTH BY SUB-GROUP 35 TABLE 4.2: EXPERIENCE OF LONG STANDING ILLNESS OR DISABILITY, BY AGE 36 TABLE 4.3: NUMBER OF PEOPLE YOU CAN TURN TO BY ‘SOCIAL ENGAGEMENT’ 39 CHAPTER 5: MENTAL HEALTH AND WELLBEING 40 TABLE 5.1: FREQUENCY OF SAMPLE SCORING GHQ12 SCORES 42 TABLE 5.2: WEMWBS: MEAN, STANDARD DEVIATION, MEDIAN, RANGE 45 TABLE 5.3: POSITIVE EFFECTS ON MENTAL HEALTH AND WELLBEING 47 TABLE 5.4: NEGATIVE EFFECTS ON MENTAL HEALTH AND WELLBEING 49 FIGURE 5.1: LEVELS OF CONTROL OVER MENTAL HEALTH. TREND SINCE 2002 50 TABLE 5.5: PERCEIVED LEVELS OF CONTROL OVER FACTORS AFFECTING MENTAL HEALTH

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CHAPTER 6: EXPERIENCE OF MENTAL HEALTH PROBLEMS 54 TABLE 6.1: EXPERIENCE OF MENTAL HEALTH PROBLEMS IN SOMEONE CLOSE. 56 TABLE 6.2: PERSONAL EXPERIENCE OF A MENTAL HEALTH PROBLEM 58 FIGURE 6.1: DISCLOSURE OF MENTAL HEALTH PROBLEMS 59 TABLE 6.3: SOCIAL IMPACT OF MENTAL HEALTH. DATA FROM 2002, 2004 AND 2006

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TABLE 6.4: SOCIAL IMPACT OF MENTAL ILL-HEALTH 62 TABLE 6.5: FACTORS IMPORTANT IN SUPPORTING RECOVERY 64 TABLE 6.6: FACTOR ANALYSIS 2 FACTOR SOLUTION 65 TABLE 6.7: FACTORS HINDERING RECOVERY 66 TABLE 6.8: MEANINGS OF RECOVERY 67 FIGURE 6.2: MESSAGE OF RECOVERY FROM PROFESSIONALS 68 FIGURE 6.3: MESSAGE OF RECOVERY FROM PEOPLE CLOSE 68 CHAPTER 7: ATTITUDES TOWARDS MENTAL HEALTH PROBLEMS 69 TABLE 7.1: ATTITUDES TO MENTAL ILL-HEALTH, BY SURVEY 71 TABLE 7.2: ATTITUDES TOWARDS MENTAL ILL-HEALTH IN SCOTLAND AND NORTHERN IRELAND

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TABLE 7.3: ATTITUDES TOWARDS MENTAL ILL-HEALTH, BY AGE AND EDUCATION

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TABLE 7.4: ATTITUDES TO MENTAL ILL-HEALTH, BY EXPERIENCE OF MENTAL HEALTH PROBLEMS

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TABLE 7.5: PERCEIVED PREVALENCE OF MENTAL ILL-HEALTH, BY SUBGROUPS 78 FIGURE 7.1: REGRESSION ANALYSIS OF PERCEIVED PREVALENCE OF MENTAL ILL-HEALTH

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CHAPTER 8: ATTITUDES TOWARDS SPECIFIC SYMPTONS OF MENTAL ILL-HEALTH

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TABLE 8.1: WILLINGNESS TO INTERACT WITH PERSON IN THE SCENARIOS – AGGREGATE RESULTS FOR 2006

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TABLE 8.2: WILLINGNESS TO INTERACT WITH PERSON IN THE SCENARIOS – MEAN RESPONSES

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TABLE 8.3: WILLINGNESS TO INTERACT WITH PERSON IN THE SCENARIOS, BY GENDER OF SUBJECT – MEAN RESPONSES

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TABLE 8.4: WILLINGNESS TO INTERACT WITH PERSON IN THE SCENARIOS, BY CONDITION DEPICTED – MEAN RESPONSES

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FIGURE 8.1: WILLINGNESS TO START WORKING CLOSELY WITH ROBERT/SHONA - INTERACTION BETWEEN GENDER AND SYMPTOMS OF PERSON IN SCENARIO

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TABLE 8.5: WILLINGNESS TO INTERACT WITH PERSON IN THE SCENARIOS, BY GENDER OF RESPONDENTS – MEAN RESPONSES

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FIGURE 8.2: WILLINGNESS TO MAKE FRIENDS WITH PERSON IN THE SCENARIOS – INTERACTION BETWEEN GENDER AND INCOME OF RESPONDENTS

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TABLE 8.6: WILLINGNESS TO INTERACT WITH PERSON IN THE SCENARIOS, BY AGE – MEAN RESPONSES

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CHAPTER 9: SOURCES OF INFORMATION ON MENTAL HEALTH PROBLEMS AND AWARENESS OF CAMPAIGNS, INITIATIVES AND PROMOTIONAL ACTIVIY

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TABLE 9.1: FORMING IMPRESSIONS AND OPINIONS ABOUT MENTAL HEALTH PROBLEMS

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TABLE 9.2: FORMING IMPRESSIONS AND OPINIONS ABOUT MENTAL HEALTH PROBLEMS, BY SUB-GROUPS

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TABLE 9.3 RECALL OF ADVERTS OR PROMOTIONS ABOUT MENTAL HEALTH 96 TABLE 9.4: AWARENESS OF MENTAL HEALTH CAMPAIGNS, INITIATIVES AND PROMOTIONAL ACTIVITY, BY AGE

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TABLE 9.5: AWARENESS OF MENTAL HEALTH CAMPAIGNS, INITIATIVES AND PROMOTIONAL ACTIVITY, BY PERSONAL EXPERIENCE OF MENTAL ILL-HEALTH

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TABLE 9.6: CORRELATION ANALYSIS OF AWARENESS OF CAMPAIGNS, INITIATIVES AND PROMOTIONAL ACTIVITY, AND ATTITUDES TO MENTAL ILL-HEALTH

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ANNEX B: SURVEY ADMINISTRATION 111 TABLE B.1: SUMMARY TABLE AND RECORD OF ACHIEVALS 112 TABLE B.2: FINAL OUTCOMES 112 TABLE B.3: REFUSAL INFORMATION 113 ANNEX G: STATISTICAL SIGNIFICANCE AND RELIABILITY 144 TABLE G.1: PREDICTED RANGES FOR DIFFERENT SAMPLE SIZES AT THE 95% CONFIDENCE INTERVAL

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TABLE G.2: SAMPLING TOLERANCES 146 TABLE G.3: DEMOGRAPHIC SUB-GROUP COMPARISONS 146 ANNEX I: ADDITIONAL MULTIVARIATE ANALYSES UNDERTAKEN 152 TABLE I.1: FACTOR ANALYSIS 4 FACTOR SOLUTION 153 ANNEX J: MENTAL HEALTH SCENARIOS – QUESTION BY QUESTION ANALYSIS

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TABLE J.1: DEPRESSION SCENARIO. LIKELY CAUSES OF DEPRESSION 156 TABLE J.2: DEPRESSION SCENARIO. SUPPORT FOR ROBERT/SHONA 158 TABLE J.3: DEPRESSION SCENARIO. SUITABLE PLACE FOR ROBERT/SHONA TO LIVE1

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TABLE J.4: DEPRESSION SCENARIO. LIKELIHOOD OF DOING SOMETHING HARMFUL/VIOLENT TO HIM/HERSELF

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TABLE J.5: DEPRESSION SCENARIO. LIKELIHOOD OF DOING SOMETHING HARMFUL/VIOLENT TO OTHERS

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TABLE J.6: DEPRESSION SCENARIO. SOCIAL INTERACTION WITH ROBERT/SHONA 161 TABLE J.7: DEPRESSION SCENARIO. DIAGNOSIS 163 TABLE J.8: SCHIZOPHRENIA SCENARIO. LIKELY CAUSES OF SCHIZOPHRENIA 165

TABLE J.9: SCHIZOPHRENIA SCENARIO. SUPPORT FOR ROBERT/SHONA 167 TABLE J.10: SCHIZOPHRENIA SCENARIO. SUITABLE PLACE FOR ROBERT/SHONA TO LIVE

168

TABLE J.11: SCHIZOPHRENIA SCENARIO. LIKELIHOOD OF DOING SOMETHING HARMFUL/VIOLENT TO HIM/HERSELF

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TABLE J.12: SCHIZOPHRENIA SCENARIO. LIKELIHOOD OF DOING SOMETHING HARMFUL/VIOLENT TO OTHERS

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TABLE J.13: SCHIZOPHRENIA SCENARIO. SOCIAL INTERACTION WITH ROBERT/SHONA

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TABLE J.14: SCHIZOPHRENIA SCENARIO. DIAGNOSIS 172 TABLE J.15: STRESS SCENARIO. LIKELY CAUSES OF STRESS 174 TABLE J.16: STRESS SCENARIO. SUPPORT FOR ROBERT/SHONA 176 TABLE J.17: STRESS. SUITABLE PLACE FOR ROBERT/SHONA TO LIVE 177 TABLE J.18: STRESS SCENARIO. LIKELIHOOD OF DOING SOMETHING HARMFUL/VIOLENT TO HIM/HERSELF

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TABLE J.19: STRESS SCENARIO. LIKELIHOOD OF DOING SOMETHING HARMFUL/VIOLENT TO OTHERS

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TABLE J.20: STRESS SCENARIO. SOCIAL INTERACTION WITH ROBERT/SHONA 179 TABLE J.21: STRESS SCENARIO. DIAGNOSIS 180

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ACKNOWLEDGEMENTS Thanks are due to the following members of the project advisory group for their advice and input throughout the project.

Simon Bradstreet, Scottish Recovery Network Wendy Brock, DG Health and Wellbeing Denise Coia, Chief Medical Office, Scottish Executive Linda Dunion, ‘see me’ Campaign Caroline Farquhar, ‘Choose Life’ National Implementation Support Team, Scottish Executive Charlie Ferrier, Communications Directorate, Scottish Executive Angela Hallam, Health Finance Directorate, Scottish Executive Gregor Henderson, DG Health and Wellbeing Allyson McCollam, Scottish Development Centre for Mental Health Lauren Murdoch, Healthcare Policy and Strategy Directorate, Scottish Executive Jane Parkinson, NHS Health Scotland Steve Platt, University of Edinburgh Julie Ramsay, Health Finance Directorate, Scottish Executive Laura Ross, Public Health and Wellbeing Directorate, Scottish Executive

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GLOSSARY OF TERMS ASIST

Applied Suicide Intervention Skills Training.

Average mental wellbeing

One of 3 classifications of mental wellbeing (the others are: good mental wellbeing and poor mental wellbeing) derived from responses to the WEMWBS section of the questionnaire. A respondent with an average mental wellbeing is one whose WEMWBS score is within one standard deviation of the mean.

CAPI

Computer Assisted Personal Interviewing – the use of computer hardware to administer surveys rather than pen and paper questionnaires

CASI Computer Assisted Self Interviewing – sections of a questionnaire set out for self-completion by the respondent

GHQ12

General Health Questionnaire. A well-established screening instrument designed to detect possible psychiatric morbidity in the general population. Respondents are asked to respond to 12 questions relating to their recent experience of particular feelings (eg happiness, depression, anxiety, self-confidence and stress)

Good mental wellbeing

One of 3 classifications of mental wellbeing (the others are: average mental wellbeing and poor mental wellbeing) derived from responses to the WEMWBS section of the questionnaire. A respondent with good mental wellbeing is one whose WEMWBS score is over one standard deviation above the mean.

High mental ill-health score One of 2 classifications of mental health (the other is low mental ill-health score) derived from the GHQ12 section of the survey. Respondents with a high mental ill-health score are those who score 4 or over for the GHQ12 and who are thus defined as displaying signs of possible psychiatric disorder.

Low mental ill-health score One of 2 classification of mental health (the other is high mental ill-health score) derived from the GHQ12 section of the survey. Respondents with a low mental ill-health score are those who score 0-3 for the GHQ12 and who are thus defined as displaying no or few signs of possible psychiatric disorder.

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Poor mental wellbeing

This is 1 of 3 classifications of mental wellbeing (the others are: good mental wellbeing and average mental wellbeing) derived from responses to WEMWBS. A respondents with poor mental wellbeing is one whose score on WEMWBS is more than one standard deviation below the mean.

SIMD

Scottish Index of Multiple Deprivation. This is the Scottish Executive's official tool for identifying small area concentrations of deprivation across all of Scotland and is relevant to policies aimed at tackling the causes and effects of interacting factors. The SIMD provides a relative ranking of 6,505 small areas (data zones) across Scotland from the most deprived (ranked one) to the least deprived in Scotland (ranked 6,505). SIMD is based on 31 indicators in the six domains of current income, employment, housing, health, education, skills and training, and geographic access to services and telecommunications.

Standard deviation

The average amount of variation around the mean for a given set of survey findings. The most commonly used measure of the spread of scores

WEMWBS

Warwick-Edinburgh Mental Well-being Scale. This has been developed as a tool for measuring positive mental wellbeing at a population level. 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 ill-health and mental ill-health.

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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

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• £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

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deprived areas of the country, and those with a low mental ill-health score2 and good mental wellbeing3. 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. 2 Mental ill-health scores were derived from the General Health Questionnaire (GHQ12) section of the survey. Further details on the GHQ12 and the associated scoring system are provided in the Glossary of Terms. 3 Respondents’ levels of mental wellbeing were derived from their responses to the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). Further details on WEMWBS and the wellbeing classification derived from the scale can be found in the Glossary of Terms.

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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

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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.

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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.

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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

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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.

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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

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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

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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

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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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CHAPTER ONE: INTRODUCTION Policy background 1.1 According to the World Health Organisation (WHO), 450 million people worldwide are affected by mental, neurological or behavioural problems at any time (WHO, 2003). In Western society depression, anxiety and stress are the most common mental health problems. Indeed, the WHO anticipates that depression will be the number one disability by 2020. 1.2 In Scotland, around a quarter of the population can expect to experience a mental health problem at some point in their lives. While this rate is in line with the UK average, other evidence suggests that Scotland faces distinct challenges in terms of tackling mental ill-health. For example, the rate of prescription of anti-depressants is higher in Scotland than in other parts of the UK and, indeed, increased from 1.5 million in 1995–1996 to 2.8.million in 2000–2001 (Munoz-Arroyo, Sutton & Morrison, 2006). Other evidence suggests that between a quarter and one third of all GP consultations in Scotland are related to mental health problems. The economic impact of mental ill-health cannot be understated. In 2004/05, the total cost of mental health problems in Scotland was £8.6 billion (SAMH,2006). And, according to the Health and Safety Executive, stress-related illness alone loses the UK industry 13 million days a year costing £3.7 billion annually to society as a whole (SEU, 2004). 1.3 Throughout Europe, the scope of mental health policy has broadened to include mental health promotion and prevention as well as the treatment of mental disorders (Muijen, 2006). This is illustrated by the consensus reached at the WHO European Ministerial Conference on Mental Health, where the 52 member states endorsed the Mental Health Declaration and Action Plan for Europe (WHO Regional Office for Europe 2005). The declaration highlights 12 areas for action and a number of priorities – among these, increasing awareness of the importance of mental wellbeing and the need to tackle stigma, discrimination and inequality are particularly pertinent. 1.4 The WHO conference invited the European Commission, a collaborating partner of the conference, to contribute to implementing the Action Plan, in line with its competencies. In response, the Commission produced the Green Paper Improving the Mental Health of the Population: towards a Strategy on Mental Health for the European Union (European Commission, 2005). The paper proposes to establish an EU-strategy on mental health which would add value by: constituting a framework for exchange and co-operation between Member States; helping to increase the coherence of actions in the health and non-health policy sectors in Member States and at the Community level; and allowing the involvement of a broad range of relevant stakeholders into building solutions. Following a consultation on the Green Paper, the Commission is currently drafting a Communication setting out a strategy on mental health. 1.5 In parallel with these developments, the Scottish Executive has continued to place mental health as a priority in its health agenda. The Health White Paper Partnership for Care (NHS Scotland, 2003) highlighted the importance of linking across areas of public policy and involving all stakeholders in actions to promote good mental health and reduce health inequalities within society. Improving Health in Scotland: the Challenge (Scottish Executive, 2003), published to accompany the White Paper, set out a framework of action for the

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Scottish Executive, NHS Health Scotland and partner agencies. More recently Delivering for Health (Scottish Executive, 2005) and Delivering for Mental Health (Scottish Executive, 2006) signalled the Scottish Executive’s continuing commitment to promoting mental wellbeing and resilience in the general population, and improving the physical health and mental wellbeing of those who experience mental ill-health. The latter is organised around 14 delivery commitments ranging from improving patient and carer experience of mental health services to the better management of long-term mental health conditions and early detection and intervention in self-harm and suicide prevention. 1.6 The National Programme for Improving Mental Health and Wellbeing is a key component of the Executive’s action in this area. The Programme was launched 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. 1.7 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 main topic areas covered in the survey were as follows:

• self-assessed general health and lifestyle • understanding of factors affecting mental health and wellbeing • experience of mental health problems • attitudes to mental illness and to people experiencing mental health problems • sources of information on mental health issues • awareness of Scottish Executive mental health improvement initiatives and

promotional activity 1.8 The survey was designed to give a baseline set of data at the beginning of the National Programme’s work and for the survey 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. 1.9 The survey was run again in 2004 using a slightly altered version of the questionnaire to reflect progress in the National Programme’s agenda. 1.10 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:

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• 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 recovery4 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 national 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

1.11 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. The 2006 survey – research aims and objectives 1.12 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 ethnicity 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

4 For the Scottish Recovery Network, recovery is not simply about the absence of symptoms, but about giving people the tools to become active participants in their own health care and having a belief, drive and commitment to the principle that people can and do recover control in their lives, even where they may continue to live with ongoing symptoms.

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• 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

1.13 The next chapter describes the methodology adopted for the research and Chapter 3 describes the profile of the survey sample. Subsequent chapters present the main findings from the survey, making comparison with the 2002 and 2004 surveys, as well as drawing comparisons with other similar surveys conducted elsewhere in the UK and overseas.

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CHAPTER TWO: RESEARCH METHODOLOGY AND ANALYSIS Questionnaire design 2.1 The original survey questionnaire was developed by a multidisciplinary advisory group. The version used in the 2006 survey was revised by members of the project’s Research Advisory Group, which comprised representatives from across the Scottish Executive, NHS Health Scotland, Edinburgh University, The Scottish Development Centre for Mental Health and representatives from the ‘Choose Life’ initiative, the ‘see me…’ campaign and the Scottish Recovery Network. 2.2 Specific topics covered in the questionnaire were as follows:

• general health • length of residency in, and satisfaction with, the local neighbourhood • informal support networks and civic participation • perceived positive and negative influences on mental health • control over factors affecting mental health • a measure of positive mental wellbeing • a measure of possible psychiatric morbidity • experience of mental health problems • telling others about mental health problems • the social impact of mental ill-health • recovery from mental ill-health • sources of information about mental health problems • awareness of adverts/promotions about mental health problems • familiarity with key mental health campaigns, initiatives and promotional activity • the perceived prevalence of mental ill-health • attitudes to mental ill-health • attitudes towards specific symptoms of mental ill-health

2.3 The latter topic area was probed using vignettes depicting people with symptoms associated with depression, schizophrenia and stress. The vignettes were adapted from a study by Link et al (1999) on public recognition of mental illness. Each vignette was constructed to meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, for the disorder in question and related to a man (called Robert) or a woman (Shona). Respondents were randomly assigned one of the vignettes and asked questions about the person depicted and the symptoms they were displaying. At the end of the section, respondents were asked to say what condition they believed the symptoms described. 2.4 Given that the survey is used to track progress towards specific outcomes, the questionnaire was designed to be comparable with that used in the 2002 and 2004 surveys. However, as in 2004, a number of refinements and additions were made with a view to improving the quality and usefulness of the data gathered. Most notably:

• the wording of the preambles to some questions was clarified • the Warwick-Edinburgh Mental Well-being Scale (WEMWBS) (NHS Health

Scotland, University of Warwick and University of Edinburgh, 2006), a battery of

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questions designed to measure positive mental wellbeing, was added to the self completion section of the survey

• the section on recovery from mental ill health was reworked. Two new questions were added focusing on factors that hinder recovery and messages of recovery received from a) health professionals and b) friends/family. Additionally the wording of several of the pre-codes in existing items was refined

• in the vignettes section, the question concerning whether Robert/Shona should have the same rights as other people was rephrased as it was felt that the original version was probably affected by social desirability bias, that is, the tendency for survey respondents to give answers which they deem to be socially acceptable

2.5 The changes had significant implications for the length of the questionnaire. To keep the interview to the target length of 30 minutes, several questions which had proved to be of limited analytical value in previous surveys were deleted and the demographics section was revised and condensed. 2.6 A full list of all of the changes made to the questionnaire for the 2006 survey is provided in Annex D. Methodology 2.7 The survey was undertaken among a random sample of the Scottish adult population (including the Highlands and Islands) between 16 October 2006 and 21 January 2007. All interviews were conducted face-to-face by experienced Ipsos MORI interviewers in respondents’ homes. 2.8 An advance letter was sent to all sampled households from Ipsos MORI. The letter was printed on Ipsos MORI headed paper, with Scottish Executive logos, and signed by the Managing Director of Ipsos MORI. The letter was designed to provide basic information about the survey but to avoid giving prominence to the issue of mental health. A copy of the advance letter can be found in Annex A. 2.9 Households were sampled as follows:

• the postcode address file (PAF) was used as the best available source for Scotland’s household population. Addresses were sorted into five geographic groups by amalgamating NHS Board areas. These were:

• Central Belt/West (Greater Glasgow & Clyde, Lanarkshire and Forth Valley); • Lothian & Fife; • Borders & South (Borders, Ayrshire & Arran, Dumfries and Galloway); • Highlands and Islands (Highland, Western Isles, Orkney & Shetland); • North East (Tayside, Grampian).

• The target number of interviews was allocated to each area in proportion to the adult

population of the area.

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• With each area, Output Areas (OAs)5 were selected with probability proportionate to the population to provide clusters of addresses within which interviews would work. A total of 99 Output Areas were selected.

• Within each of the sampled OAs, 24 addresses were selected at random. • Interviewers made at least six calls at each sampled address if there were problems

making contact, including calls during weekends and evenings. 2.10 All fieldwork was conducted using Computer Assisted Personal Interviewing (CAPI), where data is collected on laptop computers. The General Health Questionnaire (GHQ12) and WEMWBS components of the survey were administered using CASI (Computer Assisted Self Interviewing) whereby respondents are invited to enter their responses directly into the CAPI machine. Eighty percent of respondents agreed to complete the CASI module, with interviewers providing assistance to those for whom computer literacy was an issue. 2.11 The target number of interviews for the survey was 1,200 and the total number of addresses allocated was 2,372. In the event, a total of 1,216 interviews were achieved and the response rate was 57%, allowing for invalid addresses. Further information on survey administration is provided in Annex B. 2.12 To assess the extent of any bias in the sample, it is important to consider whether people who did not take part in the survey differed in socio-demographic terms from those who did. At addresses where respondents refused to participate in the survey, interviewers recorded reasons for refusals, as well as a limited amount of socio-demographic characteristics of ‘refusers’. 2.13 This data shows that, of those who refused to take part, 30% said they were too busy or they were always busy, while 16% said they never do surveys, 12% said they were put off by the subject matter and 4% said they were just not interested. These findings are consistent with outcome data for the previous waves of the survey. 2.14 Looking at the profile of non-responders, 31% were observed as being from elderly adult households, 18% were from families with children and 28% were classified as belonging to some ‘other’ type of household. For the remaining refusers, no profile information was gathered by interviewers. Ipsos MORI consistently finds that elderly households are among those most likely to decline to participate, usually because they feel that surveys are not relevant to them or that they are not well enough to take part. 2.15 The tendency for refusals to be higher among some groups than others (and we can only assume that this is the case based on the limited amount of profile data recorded by the interviewers) does not appear to have introduced any notable bias into the sample. There are two main points to note in this respect. Firstly, in spite of the relatively high level of refusals among elderly households, the survey in fact over represents elderly age groups and under-represents younger groups. The data was weighted to reflect this and to bring the achieved sample profile more into line with that of the general population. Secondly, and as the table below illustrates, the weighted profile of the sample is in line with the weighted profiles of other large scale national surveys conducted by Ipsos MORI over recent years, including the 2005 Scottish Household Survey.

5 OAs are the smallest unit of census geography for which data is provided. Each OA contains around 50 households.

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Table 2.1: Sample profile Sample Profile

‘Well? What do you think?’

2006 (unweighted)


2006 (weighted)

2001 census data

Base: All respondents (1,216) (1,216)

% % %

Male 44 48 48

Female 56 52 52

16 to 24 9 14 14

25 to 34 13 15 17

35 to 44 19 20 19

45 to 54 16 16 17

55 to 59 9 8 7

60 to 64 10 8 6

65 to 74 15 12 11

75 + 10 8 9

In paid work 51 54 54

Not in paid work 49 46 46

Source: Ipsos MORI Missing data 2.16 All respondents in the survey were given the opportunity to complete the General Health Questionnaire (GHQ12) and WEMWBS module. However, due to an error in the survey script a significant proportion of respondents were presented with only the first two questions of the GHQ12. More specifically, of the 973 respondents who agreed to complete the self completion modules, only 460 were presented with the full GHQ12 section, thus resulting in a significant amount of missing data. The survey Research Advisory Group and Ipsos MORI met to discuss the way forward in light of the omission. After reviewing a number of different options it was decided to recommend to relevant heads of division that no ameliorative action should be taken to address the omission. This recommendation was accepted by the Scottish Executive’s Deputy Director, Mental Health Division, and Deputy Director, Health Finance Directorate Analytical Services Division. The GHQ12 omission and associated methodological issues are discussed in more detail in Annex H.

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Analysis 2.17 Prior to the analysis stage, the data had to be weighted to account for the fact that only one person was interviewed per household. This meant that adults in multi-adult households had a lower chance of participating in the survey than adults in single person households. The data was also weighted by NHS Board, age and gender using 2001 census data. 2.18 For the purposes of analysis, computer tables were prepared to a specification agreed with the Scottish Executive. In the tables, responses to each survey question were analysed against a number of key variables, namely:

• Sex • Age (8 groups – 16 to 24 years through to 75 years and over) • Age interlocked with sex (6 groups – males aged 16 to 34 years, 35 to 54 years and 55

years and over; and females aged 16 to 34 years, 35 to 54 years and 55 years and over)

• Ethnicity (2 groups – White and non-White) • Working status (3 groups – Full time, part time, not working) • Household income (5 groups – ranging from less than £5,200 per annum to £36,400

or more) • Ease of managing on income (3 groups – easy, manageable, difficult) • Area Deprivation (5 bands – most to least deprived based on the Scottish Index of

Multiple Deprivation (SIMD)6 which uses data from a range of sources including, the 2001 census, the Department of Work and Pensions, the Police, the Scottish Executive, local authorities and ISD Scotland)

• Qualifications (4 groups ranging from no qualifications to professional qualifications) • Urban/rural split (6 groups ranging from most urban to most rural) • NHS Board Areas (5 groups – Borders and South, Central Belt West, Highlands and

Islands, Lothian and Fife, North East) • Long-standing illness/disability/infirmity (3 groups – Limiting condition, non-

limiting, none) • Experienced a mental health problem (3 groups – A problem of their own, someone

close with a problem, no contact at all) • General Health (2 groups – good and poor) • Psychiatric morbidity (2 groups – low and high mental ill-health) • Mental wellbeing (3 groups – poor, average, and good mental wellbeing)

2.19 In addition to these basic cross-tabulations, multivariate analyses were undertaken to explore the strength of relationships between variables. The main types of analysis that were undertaken were regression analysis, segmentation analysis, correlation analysis and the aggregation of responses across different variables. A full description of each technique is presented in Annex F. It is important to note that cross-sectional data generated in this survey can be used to establish correlations between variables but not definitively identify causation. 6 The Scottish Index of Multiple Deprivation (SIMD) identifies the most deprived areas across Scotland. It is based on 31 indicators in the six individual domains of Current Income, Employment, Housing, Health, Education, Skills and Training and Geographic Access to Services and Telecommunications.

25

2.20 Several questions in the survey were asked of only a sub-section of respondents. For example, the questions about recovery from mental ill-health were asked only of those who said they had experienced a mental health problem, which amounted to 384 people. Similarly each of the six vignettes were presented to only around 200 respondents, one sixth of the total sample. There is a limit to the amount of reliable sub-group analysis than can be undertaken on such small samples. To address this issue and maximise the explanatory potential of the survey, data from the 2002, 2004 and 2006 surveys were aggregated, thus tripling the effective sample sizes for questions which have run in all three waves of the survey. Interpretation of the data 2.21 As noted in the technical appendices to the report (see Annex G) survey respondents represent only a sample of the total population. All survey results are subject to sampling variability which means that observed differences between sub-groups may not always be statistically significant i.e. they may have occurred by chance. Throughout the report, differences between sub-groups are commented upon only where these are statistically significant – i.e. where we can be 95% confident that such a difference has not occurred by chance (p<0.05). The formula used for calculating significant differences and a guide to statistical reliability is appended in Annex G. 2.22 Where percentages do not sum to 100%, this may be due to computer rounding or multiple answers. Throughout the report, an asterisk (*) denotes any value of less than half a percent. 2.23 It is important to note that the findings presented throughout this report are based on what people say about their attitudes towards, and experiences of, mental health problems and related issues. It may be that some respondents have chosen not to reveal particular information, for example, that they have experienced a specific condition or that they hold negative attitudes towards mental ill-health. This point should be borne in mind when interpreting the data.

26

CHAPTER THREE: DEMOGRAPHIC PROFILE OF RESPONDENTS 3.1 This chapter describes the demographic profile of the respondents, focusing in particular on their age, ethnicity, household income, educational qualifications, and whether they live in an urban or rural location. 3.2 Respondents were aged between 16 and 96 years, with an average age of 50 years. Table 3.1 shows the demographic sex/age profile of the respondents and compares it to that for the 2004 and 2002 surveys. Once again the survey somewhat under-represented young people. Table 3.1: Age and sex

Age within sex

2001 Census

‘Well? What do you

think?’ 2002 weighted


think?’ 2004 weighted


think?’ 2006 unweighted


2006 weighted

Base: All respondents (4,089,945) %

(1,381) %

(1,401) %

(1,216) %

(1,216) %

Male

16-24 7.0 7.5 6.8 4.2 7.3

25-34 8.3 8.5 8.4 6.3 8.0

35-44 9.3 8.7 9.3 7.6 8.7

45-54 8.3 7.7 7.9 7.1 7.6

55-59 3.4 3.0 3.9 3.6 3.5

60-64 3.1 3.1 3.2 4.4 4.3

65-74 4.9 4.4 4.9 6.9 5.7

75 plus 3.1 3.3 3.0 3.4 2.5

Total 47.4 46.2 47.4 43.5 47.6

Female

16-24 6.9 6.1 6.8 4.7 7.0

25-34 8.8 9.2 7.6 7.2 6.7

35-44 9.8 9.1 11.3 10.9 10.8

45-54 8.5 8.2 8.6 9.0 8.1

55-59 3.6 3.9 3.7 5.4 4.4

60-64 3.4 4.5 3.4 5.2 3.7

65-74 6.0 8.3 6.4 7.6 6.7

75 plus 3.1 4.6 4.9 6.5 5.0

Total 52.7 53.9 52.7 56.5 52.4

27

3.3 Sixty five per cent of the respondents had no children (under 16) in the household. Sixteen per cent had one child (under 16), 13% had two and 5% had three or more. 3.4 In terms of their ethnicity, the majority of respondents described themselves as White/Scottish (84%) and 14% assigned themselves to another White category. The remainder of the sample were in other non-white categories, as illustrated in table 3.2. Table 3.2: Ethnicity

Ethnicity

Cen

sus 2

001

‘Wel

l? W

hat d

o yo

u th

ink?

’ 20

02

(wei

ghte

d)

‘Wel

l? W

hat d

o yo

u th

ink?

’ 20

04

(wei

ghte

d)

‘Wel

l? W

hat d

o yo

u th

ink?

’ 20

06

(unw

eigh

ted)

‘Wel

l? W

hat d

o yo

u th

ink?

’ 20

06

(wei

ghte

d)

All respondents (5,062,011) (1,381) (1,401) (1,216) (1,216)

% % % % %

White 98.0 99.0 97.8 98.0 98.0 Scottish 88.1 89.8 87.7 84.6 84.4

Other British 7.4 7.8 8.3 11.4 11.8

Irish 1.0 0.4 0.3 0.7 0.7

Any other White background 1.5 1.0 1.5 1.3 1.1

Mixed 0.2 0.1 0.3 0.4 0.3 Any mixed background 0.2 0.1 0.3 0.4 0.3

Asian, Asian Scottish or Asian British

1.3 0.6 1.2 1.0 1.4

Indian 0.3 0.2 0.3 0.4 0.4

Pakistani 0.6 0.2 0.2 0.3 0.7

Bangladeshi 0.0 - - - -

Chinese 0.1 0.2 0.4 - -

Any other Asian background 0.3 - 0.3 0.3 0.3

Black, Black Scottish or Black British

0.1 0.1 0.7 0.4 0.4

Caribbean 0.0 - 0.2 - -

African 0.1 0.1 0.3 - 0.4

Any other Black background 0.0 - 0.2 0.4 -

Other ethnic group 0.2 0.1 - - -

Source: Ipsos MORI

28

3.5 Average household income for the sample was £22,192 per annum, which is higher than the comparable figure from both the 2005 Scottish Household Survey and previous waves of ‘Well? What do you think?’. In part, this is likely to reflect the fact that the proportion of people refusing to reveal their income was relatively high in the present survey, at 24%7 (table 3.3). Looking at the figures in more detail, the proportions of respondents with a household income of £10,400 or under and £20,800 or over have remained static over the 3 waves of ‘Well? What do you think?’. However, there has been a decrease since 2004 in the proportion with a household income of between £10,400 and £20,800. Again, the high number of refusals recorded in 2006 may help to account for these differences. 3.6 Around half of respondents said they found it easy to manage on their income, while 31% said they found it manageable and 11% found it difficult. Since 2002, there has been a small, but consistent, move towards people finding it easier to manage on their household income. Table 3.3: Annual household income

Annual household income

Scottish Household

Survey 2005-2006

‘Well? What do

you think?’ 2002

weighted

‘Well? What do

you think?’ 2004

weighted

‘Well? What do

you think?’ 2006

unweighted

‘Well? What do

you think?’ 2006

weighted

Base: All respondents (31,013) (1,381) (1,401) (1,216) (1,216)

% % % % % Under £3,120 per annum 1 1 1 1 1 £3,120 and less than £5,200 per annum 3 6 5 5 3 £5,200 and less than £10,400 per annum 22 12 13 14 11 £10,400 and less than £15,600 per annum 21 11 15 11 9 £15,600 and less than £20,800 per annum 15 13 12 8 8 £20,800 and less than £26,000 per annum 11 10 8 8 9 £26,000 and less than £31,200 per annum 9 8 7 5 6 £31,200 and less than £36,400 per annum 7 7 4 4 5

£36,400 or more per annum 11 9 11 9 11 Mean £20,424.40 £20,838.44 £20447.35 £20093.95 £22192.16 Refused n/a8 11 12 25 24 Don’t know n/a 12 11 9 13

Source: Ipsos MORI

7 The reason for this difference is unclear. Certainly, there are no obvious methodological explanations - no changes were made to the relevant section of the CAPI script or to the accompanying showcard for the 2006 survey. 8 In the Scottish Household Survey, the income of respondents who have refused to answer or given a ‘don’t know’ response is imputed from other data collected in the survey.

29

Table 3.4: Ease of managing on household income How easy or difficult do you find it to manage on your household’s income?

Total


think?’ 2002 (weighted)




think?’ 2006 (unweighted)



Base: All respondents (1,381) (1,401) (1,216) (1,216)

% % % %

Very easy 13 14 18 18

Fairly easy 30 33 34 34

Manageable 40 36 31 31

Fairly difficult 11 10 9 8

Very difficult 6 4 4 3

Don’t know - 3 4 6

Source: Ipsos MORI

3.7 Consistent with findings from previous waves of the survey, around half (54%) of respondents were in paid work while 24% were retired. Three per cent were registered unemployed/signing on for Job Seekers Allowance (JSA), 4% were at home/not seeking work, 7% were long term sick or disabled and 8% were in full time education.

30

Table 3.5: Working status Which of these apply to you?

Total






think?’ 2006 (unweighted)



Base: All respondents (1,381) (1,401) (1,216) (1,216)

% % % %

In paid work 53 56 51 54

Local or government training scheme (GTS)

* * 1 1

Modern Apprenticeship * * * *

Registered unemployed/signing on

for Job Seekers Allowance

3 2 3 3

Not registered but seeking work

1 1 1 1

At home/not seeking work

6 5 4 4

Long term sick or disabled

7 6 6 6

Retired 25 22 30 24

Full time education 3 5 8 8

Carer N/A N/A 2 2

Other 1 2 4 4

Source: Ipsos MORI

31

3.8 Nine per cent of respondents said that their highest educational or professional qualification was the school leaving certificate/new National Qualification Access Unit. Fifteen per cent said it was O Grade/Standard Grade/GCSE level or equivalent, while 8% said it was at SEC Higher Grade/CSYS/A level or equivalent. Eleven per cent said they had achieved HNC, HND, SVQ Levels 4 or 5 or equivalent, 12% had a first degree and 10% had obtained professional qualifications. As table 3.6 shows, these results are consistent with those for the 2004 survey. Data for 2002 is not provided as the question wording differed slightly in that wave of the survey. Table 3.6: Qualifications

Highest qualification


2004 (weighted)


2006 (unweighted)


2006 (weighted)

Base: All respondents (1,401) %

(1,216) %

(1,216) %

School Leaving Certificate, new National Qualification Access Unit

8 10 9

O Grade, Standard Grade, GCSE, CSE, Senior Certificate or equivalent

14 14 15

GSVQ Foundation or Intermediate, SVQ Level 1 or 2, SCOTVEC Module or

equivalent, New National Qualification Access 3 Cluster, Intermediate 1 or 2

4 3 3

SEC Higher Grade/New National Qualification Higher or Advanced

Higher/CSYS/A level, Advanced Senior Certificate or equivalent

8 7 8

GSVQ Advanced, SVQ Level 3, ONC, OND, SCOTVEC National Diploma or

equivalent

4 4 5

City and Guilds 7 7 6 HNC, HND, SVQ Levels 4 or 5 or

equivalent11 10 11

First degree, Higher degree 12 11 12 Professional qualifications e.g. teaching,

Accountancy8 11 10

None of these 24 24 22

Source: Ipsos MORI

32

3.9 While the sample was once again distributed proportionate to the population among NHS Board Areas, its urban/rural profile9 differed somewhat to that of both the 2005 Scottish Household Survey and previous waves of ‘Well? What do you think?’ Specifically a lower proportion in the present sample lived in ‘other urban areas’ (band 2), while a higher proportion lived in accessible rural areas (band 5). Table 3.7: Urban/rural composition

Urban/rural composition

Scot

tish

Hou

seho

ld

Surv

ey 2

005-

2006

‘Wel

l? W

hat d

o yo

u th

ink?

’ 200

4

(wei

ghte

d)

‘Wel

l? W

hat d

o yo

u th

ink?

’

200

6 (u

nwei

ghte

d)

‘Wel

l? W

hat d

o yo

u th

ink?

’ 2

006

(w

eigh

ted)

Base: All respondents (31,013) %

(1,401) %

(1,216) %

(1,216) %

Large urban areas (band 1) 41 36 39 42

Other urban areas (band 2) 29 29 23 22

Accessible small towns (band 3) 9 12 7 7

Remote small towns (band 4) 4 4 4 3

Accessible rural (band 5) 12 12 19 21

Remote rural (band 6) 6 8 7 5

Source: Ipsos MORI

9 For the purposes of the survey, the Scottish Executive’s six fold urban/rural classification had been adopted. This is based on settlement size and remoteness (measured by drive times) allowing more detailed geographical analysis to be conducted on a larger sample size. The classification being used in this report is the latest version.

33

CHAPTER FOUR: GENERAL HEALTH AND LIFESTYLE 4.1 This chapter considers respondents’ self assessed general health and their experience of any long-standing limiting conditions. It also examines their informal support networks and the extent to which they are involved in their local communities. General Health 4.2 Around three quarters (76%) of respondents rated their general health as good (42%) or very good (34%). Meanwhile, 18% said their general health was fair and 6% said it was bad or very bad (figure 4.1 below). It is difficult to compare these results directly with findings from the previous surveys due to changes in the question wording. Nonetheless, they appear to be consistent with the 2004 survey findings, when 83% of respondents rated their health as either very good or fairly good. Furthermore they are comparable with results from the 2003 Scottish Health Survey in which 74% rated their general health as good or very good, 18% rated it as fair and 4% as bad or very bad (Scottish Executive 2005). Figure 4.1: Ratings of general health

Q How is your health in general?

Good42%

Bad5%

Fair18% Very good

34%

Very Bad1%

4.3 Predictably, and as can be seen in table 4.2 (below), the proportion rating their general health as good or very good decreased with age, from 90% among people aged 16 to 24 years, to 77% of those aged 45 to 54 years and 41% of those aged 75 and over. 4.4 There were also some differences by key economic indicators. Respondents in higher income brackets (i.e. those with a net income of £15,600 per annum or more) were more likely than those with lower incomes to rate their general health as good or very good, and

34

people living in the least deprived areas of the country were more likely to do so than those in more deprived areas. Similarly, people who said they found it easy to manage on their income were more likely to rate their health as good or very good than those who said they found it difficult. Indeed, of those who said they found it difficult to manage, 1 in 5 rated their general health as poor, which is three times higher than average (21% versus 4% of those who found it easy to manage). 4.5 Analysis by NHS Board area reveals that respondents living in Lothian and Fife and the North East were more likely to rate their general health as good or very good than those in the West Central Belt and Highlands and Islands. 4.6 People displaying no or few signs of psychiatric disorder (as reflected in their scores on the GHQ12) gave more positive ratings of their general health than those with a possible psychiatric disorder10. Conversely, those with good mental wellbeing (according to their WEMWBS score) gave better general health ratings that those with poor mental wellbeing.11

10 The GHQ12 is a measure of possible psychiatric morbidity or mental ill-health. Each item in the GHQ12 asks whether the respondent has experienced a particular symptom or feeling on a scale ranging from ‘less than usual’ to ‘more than usual’. In the present study responses were scored in accordance with the bimodal scoring method outlined in A Users Guide to the General Health Questionnaire. Specifically, respondents were divided into two groups: those with an overall score of 4 or more, who are considered to exhibit signs of possible psychiatric disorder (hereafter referred to as high mental ill-health score) and those with scores of under 4 who are considered to display no or few signs of possible psychiatric disorder (hereafter referred to as a low mental ill-health score). 11 WEMWBS is a relatively new scale which measures positive mental wellbeing. Because validation of the WEMWBS is ongoing, there is, as yet, no set approach to classifying responses to the scale. For the purposes of the present study it was decided to split the sample into three groups, on the basis of their combined scores for the constituent items of WEMWBS. The three groups are those with ‘good’ mental wellbeing (a WEMWBS score of over one standard deviation above the mean score), those with ‘average’ mental wellbeing (a WEMWBS score within one standard deviation of the mean) and those with ‘poor’ mental wellbeing (a WEMWBS score of more than one standard deviation below the mean).

35

Table 4.1: Ratings of general health by sub-group Q: I’d like to start by asking you some general questions about your general health and lifestyle. First of all, how is your health in general. Would you say it was…?

Very good

Good Fair Bad Very bad

Don’t know

% % % % % %

All (1,216) 34 42 18 5 1 *

16-24 (108) 49 40 10 * - -

25-34 (164) 37 46 11 4 1 -

35-44 (225) 42 40 15 2 1 -

45-54 (196) 34 43 14 5 2 1

55-59 (110) 26 41 22 9 1 -

60-64 (116) 17 29 22 9 4 -

65-74 (177) 26 42 26 6 1 -

75+ (120) 13 28 40 14 4 -

Annual household income less than £5,200 (71)

22 30 28 17 3 -

Annual household income £36,000 or more (114)

46 43 8 1 - 1

Find it easy to manage on income (630)

38 41 17 3 1 -

Find it difficult to manage on income (156)

19 37 23 18 3 -

SIMD – least deprived areas (band 5) (213)

41 44 13 1 1 -

SIMD – most deprived areas (band 1) (212)

23 44 21 11 1 1

Borders and South NHS Board Area (137)

32 40 22 4 2 -

Central Belt NHS Board Area (367) 27 44 21 6 2 1

Highlands and Islands NHS Board Area (210)

30 40 19 8 2 -

Lothian and Fife NHS Board Area (268)

45 37 13 5 1 -

North East Health NHS Board Area (234)

36 45 14 3 1 -

Low mental ill-health score (379) 40 43 15 1 * -

High mental ill-health score (81) 22 40 21 11 4 2

Good mental wellbeing (133) 56 33 10 1 - N/A

Poor mental wellbeing (133) 12 42 29 13 3 N/A

Source: Ipsos MORI

36

Long standing limiting conditions 4.7 As in the 2004 survey, a third (32%) of respondents had a long standing illness or disability. This is consistent with the result from the 2004 survey (31%) but eight percentage points fewer than in the 2003 Scottish Health Survey (40%). As would be expected, in broad terms, experience of long standing illness or disability increases with age (see table 4.2 below). There were no differences by gender. Table 4.2: Experience of long standing illness or disability, by age

Q: Do you have any long standing illness, disability or infirmity. By long standing I mean anything that has troubled you over a period of time, or that is likely to affect you over a period of time?

% saying yes

Base: All (1,216)

All 32

Male 31

Female 34

16-24 (108) 14

35-34 (164) 21

35-44 (225) 21

45-54 (196) 32

55-59 (110) 41

60-64 (116) 57

65-74 (177) 49

75+ (120) 59

Source: Ipsos MORI

4.8 Of those who have a long standing illness or disability, almost 7 in 10 (66%) said it limits their activities in some way. This is consistent with the comparable result from the 2004 ‘Well? What do you think?’ study (63%) and from the Scottish Health Survey. Length of residency in and satisfaction with local neighbourhood 4.9 The environment in which people live may have an important impact on their mental wellbeing. Accordingly respondents were asked both how long their had lived in their current neighbourhoods and how satisfied they were with their neighbourhoods. 4.10 The majority of respondents - seven in ten - had lived in their current neighbourhoods for at least five years. This includes 35% who had lived in their neighbourhoods for between 5 and 20 years and 36% who had done so for more than 20 years. Thirteen per cent had lived

37

in their neighbourhood for between 2 and 5 years, 7% for between one and two years and 9% for less than a year. 4.11 Younger respondents, aged 16 to 34 years, were more likely than those aged 35 and over to have lived in their neighbourhood for only one to two years. This is perhaps unsurprising as it is between the ages of 16 and 34 that young people are likely to move away from home, whether to attend university or college, and/or to set up their own home. Mobility was also higher among those in the most urban area than in the most rural area. There were no differences in length of residency by self-reported experience of mental ill-health, mental ill-health score or mental wellbeing. 4.12 Around nine in ten (91%) respondents were satisfied with their local neighbourhood, with 57% saying they were very satisfied. Of those remaining, 6% said they were dissatisfied with their local neighbourhood and 4% said they were neither satisfied nor dissatisfied. These figures represent a positive trend in neighbourhood satisfaction since 2004, when 87% were satisfied with their neighbourhoods - with 52% very satisfied - 6% were dissatisfied and 4% were neither satisfied nor dissatisfied. 4.13 Those living in less deprived areas of the country (bands 4 and 5) were significantly more likely to be satisfied with their neighbourhoods than those in the most deprived areas (94% and 94% versus 82% respectively). There were also differences by rurality/urbanity, with those in the most rural locations being significantly more satisfied that those in the most urban locations (98% versus 80%). Meanwhile, people living in the North East NHS Board area tended to be more positive about their neighbourhoods than those in the Borders and South, Central Belt West, and Highlands and Islands NHS Board areas (96% versus 90%, 87% and 93% respectively). All of these findings are consistent with results from the 2004 survey. 4.14 Again, there were no differences by experience of mental ill-health or mental ill-health scores, but people displaying good mental wellbeing were more likely than those with poor mental wellbeing to be satisfied with their neighbourhood (73% of those with good mental wellbeing said they were very satisfied, compared with 40% of those with poor mental wellbeing). Contact with friends/relatives informal support networks and civic participation 4.15 Having few close friends or relatives has been associated with a greater likelihood of experiencing symptoms of mental ill-health across the lifespan (see, for example, Cattan et al., 2005; Miller, 1979; Ueno, 2005: Putnam 2000). Accordingly, the survey includes questions to gauge how often respondents see friends and relatives who do not live with them and whether they have people they could rely on if they were experiencing personal difficulties. 4.16 With regard to how often they see friends or relatives who are not living with them, two in five (41%) respondents said on most days, and roughly the same proportion (42%) said once or twice a week. Meanwhile 12% said once or twice a month and 5% less often than once a month.

38

4.17 The youngest and oldest age groups were among those most likely to see friends and relatives on most days (58% of people aged 16 to 24 years and 45% of people aged 75 or over versus, for example, 33% of people aged 35 to 44 years). To some degree, these findings are intuitive. The youngest group may be more likely than other respondents to be in education and thus in contact with classmates on a frequent basis. They may also be more likely to have the spare time to spend with friends. The oldest group, meanwhile, may be receiving ongoing care from family members and/or seeing friends regularly at day centres and other similar social gatherings. In contrast, people in the middle age ranges may be too busy with work and family commitments to see friends and relatives with such regularity. 4.18 People living in the Highlands and Islands were more likely than those in other NHS Board areas to see their friends and relatives on most days (54% versus 37% in the Central Belt West and Lothian and Fife). This may reflect the existence of stronger social networks in more rural areas, as well as the higher than average proportions of elderly residents. 4.19 There are no differences by self-reported experience of mental health or mental ill-health scores but people with good mental wellbeing were more likely than those with poor mental wellbeing to see friends or relatives at least once or twice a week (91% versus 73%). 4.20 The majority of respondents also felt they had people they could turn to if they were experiencing personal difficulties. Specifically, 93% said they would have someone to turn to if they were ill in bed and 84% said they would have someone to turn to if they were experiencing financial difficulties and needed to borrow money. The average number of people respondents felt they would be able to turn to in the event of a serious personal crisis was six. There was little variation in the findings by key sub-group but consistent with the research cited above, people who had had personal experience of mental ill-health were less likely than those with no such experience to say they had people they could rely on if they were ill in bed (89% versus 94%) or in financial difficulty (79% versus 87%). 4.21 Again, all of these findings are consistent with results from the 2004 survey. (The questions were not asked in 2002). 4.22 As well as considering respondents’ informal support networks, the survey included a question to gauge their level of civic participation, and specifically whether they had given up free time to be a volunteer or organiser for any charities, clubs or organisation. As in 2004, one in five (20%) said they had done so – although the figure was significantly higher among people aged 60 to 64 years old (26%), those with a household income of £36,400 or more per annum (34%) and those living in the most rural areas of the country (35%). Additionally, those with good mental wellbeing appear to be more likely to have given up time to be a volunteer or organiser than those with poor mental wellbeing (29% versus 14%). While we cannot tell from the data whether people with good mental wellbeing are more likely to get involved in volunteering and organising, or whether these activities themselves contribute to positive mental wellbeing, the findings are nonetheless consistent with Putnam’s assertion that regular club attendance, volunteering, entertaining or church attendance is a key predictor of life happiness (Putnam 2000: 333). 4.23 To explore further the data on informal support networks and civic participation, an analysis was undertaken aimed at identifying whether there is a link between the number of people respondents feel they can turn to in a crisis and the extent to which they are socially

39

engaged. For the purposes of the analysis, a composite social engagement variable was created using the four measures analysed above namely:

• The frequency with which respondents saw friends or relatives who are not living with them

• Whether respondents felt they had someone they could turn to if they were experiencing financial difficulties

• Whether respondents felt they had someone they could turn to if they were ill in bed • Whether they had given up time to work as a volunteer or organiser

4.24 Respondents were coded as ‘more socially engaged’ if they gave a positive response on at least 312 of these measures, and ‘less socially engaged’ if they gave a positive response on fewer than 3. For the first measure a positive response was defined as: ‘on most days’ or ‘once or twice a week’. It was hypothesised that there would be a positive relationship between the number of people respondents felt they could turn to in a crisis and their level of social engagement. As table 4.3 (below) shows, bivariate analysis confirmed this hypothesis: Respondents who were more socially engaged had significantly more people they could turn to than those who were less so. Indeed, respondents who were less socially engaged were three times more likely than those who were more socially engaged to say they had nobody they could turn to in the event of a serious personal crisis. Although this finding is intuitive, it is nonetheless important as it illustrates that civic participation can have psychosocial benefits when one encounters stressful life events. Table 4.3: Number of people you can turn to by ‘social engagement’

If you had a serious personal crisis, how many people do you feel you could turn to for support?

More socially engaged

Less socially engaged

Base: (892) %

(292) %

None 23 78

1-3 people 63 37

4-7 people 80 20

8-12 people 83 17

13-20 people 89 11

21+ people 74 26

Source: Ipsos MORI

12 3 was chosen as the cut off point as it represented a majority of positive responses

40

CHAPTER FIVE: MENTAL HEALTH AND WELLBEING 5.1 This chapter examines findings from the GHQ12 component of the survey, which was used to gauge levels of possible psychiatric morbidity among the population; and from the Warwick-Edinburgh Mental Well-being Scale (WEMWBS), designed to assess positive mental health. It also looks at the factors respondents feel have a positive or negative effect on their mental health. The dual dimensional model of mental health 5.2 In Europe, there is a shared principle of enhancing positive mental health rather than focusing exclusively on mental ill-health (Jane-Llopis & Anderson, 2006) and Scotland is at the forefront of driving this principle forward. Indeed mental health policy in Scotland integrates this two dimensional model of mental health which brings together mental health improvement (i.e., health promotion and prevention) and care, treatment and support. Positive mental health is defined as “a state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (Jane-Llopis & Anderson 2006). 5.3 Consistent with this focus on the dual dimensional model of mental health, the survey included both the General Health Questionnaire (GHQ12) - a well established screening instrument designed to detect possible psychiatric morbidity in the general population - and the new Warwick-Edinburgh Mental Well-being Scale (WEMWBS), designed to measure positive mental wellbeing. The GHQ12 5.4 The GHQ12 was included in the survey for the first time in 2004. Each item in the GHQ12 consists of a question asking whether the respondent has recently experienced a symptom or feeling (eg happiness, depression, anxiety, self-confidence, and stress) on a scale ranging from ‘less than usual’ to ‘more than usual’. The GHQ12 is traditionally administered using a paper and pen self-completion approach. However, because the present survey is conducted using CAPI, respondents were instead invited to enter their responses directly into the interviewer’s computer. Interviewers provided assistance to those for whom computer literacy was an issue. 5.5 Although 973 respondents agreed to complete the self-completion module, only 460 respondents were presented with the full GHQ12 section with the remainder completing only the first two questions. This was due to an administrative error in the scripting of the survey (full details on this omission are included in Annex H). Nonetheless, the sample of 460 was judged to be adequate for basic analyses of the findings. The rationale underpinning this judgement was three-fold. Firstly, a preliminary analysis of profile and attitudinal data for the sample of 460 found that it did not differ significantly from the wider sample and thus could be said to be broadly representative and free from any systematic bias. Secondly, the distribution of responses to the GHQ12 was in line with that recorded in the 2004 survey which further reinforced confidence in the data. Thirdly, and in terms of statistical reliability,

41

the decrease in the achieved number of responses resulted in only a 1% increase in sampling tolerances, vis a vis the full sample. 5.6 The completed GHQ12 sections were scored according to the bimodal scoring method outlined in A Users Guide to the General Health Questionnaire (Goldberg and Williams, 1991). A score of 1 was allocated to an item if the respondent had been experiencing the symptom or behaviour described more than usual, and a score of 0 was given if the respondent had not done so. 5.7 These scores were summed to give a total GHQ12 score for each respondent, which ranged from zero to 12. The scores were then recoded into a binary variable; scores of 0-3 were recoded as ‘low mental ill-health scores’ (no or few signs of possible mental health problems) and scores of 4+ were recoded as ‘high mental ill-health scores’ (possible mental health problems). Table 5.1 (below) presents the results of the analysis together with comparable data from the 2004 survey (The GHQ12 was not included in the 2002 survey). Throughout this report, the GHQ12 binary variable is used as a key analysis variable. 5.8 There are no significant differences between the results for the 2004 and 2006 surveys, with around four in five respondents in each case classified as having a ‘low mental ill-health score’ and around one in five a ‘high mental ill-health score’. The results are also consistent with findings from the 2003 Scottish Health Survey, in which 15% were classified as having a low score and 85% a high score (Scottish Executive 2005).

42

Table 5.1: Frequency of sample scoring GHQ12 scores GHQ12 Score


2004


2006

Base: All respondents who answered the GHQ12 (1,300) (460)

Total points scored on GHQ12 % %

0 50 52

1 16 18

2 10 7

3 6 7

4 3 4

5 3 3

6 3 2

7 2 2

8 2 2

9 1 2

10 1 *

11 1 *

12 2 2

GHQ12 score grouped

0-3 (low mental ill-health score) 82 83

4+ (high mental ill-health score) 18 17

TOTAL 100 100

Source: Ipsos MORI

WEMWBS 5.9 In addition to the GHQ12, the 2006 survey also included the Warwick-Edinburgh Mental Well-being Scale (WEMWBS), designed to measure positive mental wellbeing. WEMWBS was recently developed by researchers at Warwick and Edinburgh Universities as a user-friendly and psychometrically sound tool for measuring positive mental wellbeing at a population level in Scotland. It is intended to complement standard scales which measure ill-health and mental health problems (see Tennant et al, 2006). Currently, WEMWBS is undergoing validation for use in Scotland and the UK. To date, it has been validated in studies among students and in the autumn 2006 wave of the Health Education Population

43

Survey. The 2006 ‘Well? What do you think?’ survey was felt to present another suitable validation opportunity. 5.10 WEMWBS comprises 14 separate statements describing feelings relating to mental wellbeing. For each statement, respondents are asked to indicate how often they have felt this way over the last two weeks, using a 5 point scale (none of the time, rarely, some of the time, often, all of the time). The scale represents a score for each item from 1 to 5 respectively. The overall score for WEMWBS is calculated by totalling the scores for each item. The minimum score possible from the scale is 14 while the maximum is 70. The higher a person’s score is, the better his/her level of mental wellbeing. 5.11 In the previous validation exercises cited above, WEMWBS was found to be normally distributed, to correlate highly with other measures, and to have a single underlying factor – that is, to tap one underlying concept i.e. mental wellbeing (Tennant et al 2006). These tests were re-run using the data from the current survey to determine if the same was found with general population data. In the event, WEMWBS was found to be normally distributed among the general population, to correlate strongly13 with the GHQ12 and to have a single underlying factor. 5.12 Respondents’ mean score on WEMWBS was 51.05 and the standard deviation was 8.54. As table 5.2 shows, there was some sub-group variation. People in the top income bracket had higher mean scores – i.e. better mental wellbeing – than those in the lowest bracket. Similarly, those who found it easy to manage on their income scored more highly than those who found it difficult to manage. There were also differences by self-assessed general health status: people who said their general health was good or very good obtained higher mean scores than those said their health was bad or very bad. 5.13 Analysis by experience of mental ill-health revealed that those who reported having no such experience (either personal or proxy) had higher scores than those who had personally experienced a problem. And, consistent with the finding that the GHQ12 and WEMWBS are highly correlated, people displaying no or few signs of psychiatric disorder had higher mean scores than those with a possible psychiatric disorder. There were no significant differences by gender or age. 5.14 As discussed in the previous section, respondents’ GHQ12 scores were used to derive a binary analysis variable indicating whether or not they exhibited signs of possible psychiatric disorder. The variable was created by following a coding procedure outlined in the GHQ manual. As WEMWBS is a relatively new scale no analogous classification system exists. As a result, a categorical variable was derived for the purposes of this report by dividing the survey population into three groups as follows: (i) those with “good mental wellbeing” (a WEMWBS score of over one standard deviation above the mean), (ii) those with “average mental wellbeing” (a WEMWBS score of within one standard deviation of the mean) and those with “poor mental wellbeing” (a WEMWBS score of more than one standard deviation below the mean)14. This resulted in 14% of people being classed as having “good mental wellbeing”, 73% of people were classed as having “average mental wellbeing”

13 The correlation coefficient was -0.542 14 The three categories were selected following initial analysis of respondents’ WEMWBS results which revealed that respondents’ scores were either in line with or at least one standard deviation above or below the mean.

44

and 14% of people with “poor mental wellbeing.” This three-fold classification is used as a key analysis variable throughout this report.

45

Table 5.2: WEMWBS: Mean, Standard Deviation, Median, Range WEMWBS scores – Descriptive statistics Mean Standard

Deviation Median Minimum Maximum

Base: All respondents

All (973) 51.05 8.54 52 14 70

Male (529) 51.21 8.40 52 20 70 Female (687) 50.92 8.66 52 14 70 16-24 (108) 51.25 7.81 52 29 68 25-34 (164) 50.55 7.23 51 20 70 35-44 (164) 51.01 8.80 51 22 70 45-54 (225) 49.75 9.05 51 20 70 55-59 (196) 50.89 8.75 51.5 18 69 60-64 (116) 51.78 8.32 52 33 70 65-74 (177) 52.63 9.13 52.5 22 70 75+ (120) 51.18 8.99 51 14 70

Easy to manage on household income (630) 52.48 8.07 53 20 70

Difficult to manage on household income (156) 46.25 9.47 47 18 70

Household income of less than £5,200 (71) 46.82 9.11 47 18 70

Household income of more than £36,400 (114) 52.22 6.98 52.5 36 67

Experience a mental health problem of their own (384) 47.78 9.22 48 18 70

No experience of mental health problems (298) 52.41 8.60 52 14 70

Low mental ill-health score (379) 52.87 7.58 53 14 70 High mental ill-health score (81) 41.91 8.87 42 20 63

Good or very good general health (882) 52.38 7.92 52 20 70

Bad or very bad general health (93) 43.33 10.18 43 18 69

Source: Ipsos MORI

46

Positive effects on mental health and wellbeing 5.15 Respondents were asked what sorts of things have a positive or good effect on their own emotions or mental health and wellbeing. Although the structure and wording of the question differed slightly from that used in previous surveys (and the results are therefore not directly comparable), findings were very similar to those recorded in 2002 and 2004. Specifically, spending time with family (30%) and leisure activities, hobbies and a social life (28%) were the factors most commonly mentioned, followed by spending time with friends (19%), weather (14%) and supportive relationships with family, partners or friends (11%). 5.16 As illustrated in table 5.3, there was significant variation by gender and age. Women were more likely than men to cite family and friends as a positive influence on mental health, while the reverse was the case with regard to leisure activities, hobbies and a social life. Younger age groups were more likely than older age groups to mention work and having enough money or a good income. On the other hand, older age groups were more likely than younger age groups to cite weather and being healthy. This latter finding is particularly pertinent given the link between old age and ill-health, highlighted in the previous chapter. 5.17 There was also some variation by key economic measures. In particular, people in the highest household income category (£36,400 or more per annum) were more likely than lower income groups to mention seeing friends and family, and working patterns as positive influences. Meanwhile, those who found it difficult to manage on their income were more likely than those who found it easy to manage to mention having enough money. These sub-group differences are broadly consistent with the findings from 2004.

47

Table 5.3: Positive effects on mental health and wellbeing Q What sorts of things, if any, have a positive or good effect on your own emotions or mental health and wellbeing?

Fam

ily /

seei

ng

fam

ily /

spen

ding

tim

e w

ith fa

mily

Lei

sure

act

iviti

es /

hobb

ies /

soci

al li

fe

Frie

nds /

seei

ng

frie

nds /

spen

ding

tim

e w

ith fr

iend

s

Wea

ther

Supp

ortiv

e re

latio

nshi

ps w

ith

fam

ily /

part

ner

/ fr

iend

sW

ork

/ wor

king

/ w

ork

patt

erns

Bei

ng h

ealth

y

Hav

ing

enou

gh

mon

ey /

good

in

com

e

Hol

iday

s/br

eaks

Base: All respondents % % % % % % % % % All (1,216) 30 28 19 14 11 11 8 8 8 Men (578) 27 32 14 12 13 12 7 10 6 Women (638) 32 24 24 16 10 10 9 6 9

16-24 (108) 24 41 41 4 7 14 2 4 4

35-34 (164) 29 28 24 12 15 19 6 11 10

35-44 (225) 38 20 14 15 15 15 10 12 9

45-54 (196) 30 26 15 13 10 12 7 10 9

55-59 (110) 26 28 10 17 13 13 11 6 8

60-64 (116) 34 24 14 22 7 5 12 11 7

65-74 (177) 29 29 14 20 9 1 12 3 7

75+ (120) 21 28 11 12 10 2 9 1 4

Household income of less than £5,200 (71)

19 35 16 19 4 4 6 4 2

Household income of more than £36,400 (114)

43 29 28 14 13 22 13 6 12

Easy to manage on household income (630)

32 27 21 15 12 12 8 6 9

Difficult to manage on household income (156)

31 30 16 15 12 11 8 13 3

Source: Ipsos MORI

Negative effects on mental health and wellbeing 5.18 Asked what sorts of things have a negative or bad effect on their emotions or mental health and wellbeing, respondents most commonly mentioned weather (13%) and work or having too much work (12%). These factors were closely followed by not having a good income or enough money (10%) and physical illness (8%). Again, although these results are

48

not directly comparable with those for 2004, the rank ordering of responses is broadly similar. 5.19 Again, there was notable variation in the 2006 data by gender and age. Women, and particularly older women, were more likely than men to mention the weather as a negative influence. People aged 75 and over were more likely than younger groups to mention physical illness, while younger respondents were more likely to mention work and not having enough money (table 5.4). 5.20 Higher income groups (i.e. those earning £15,600 or more per annum) were more likely than lower income groups to mention work and work patterns. This was reflected in the SIMD analysis, with those in the least deprived areas being more than three times as likely to mention work and work patterns as those in the most deprived areas. Of course, in part this may be a function of the fact that people in the most deprived areas are less likely to be working. People who found it difficult to manage on their income were more likely than those who find it easy to mention not having enough money as a negative influence on their mental health and wellbeing. The fact that people in higher income groups were more likely than lower income groups to mention work and/or work patterns as a positive and a negative factor is interesting and worthy of further investigation.

49

Table 5.4: Negative effects on mental health and wellbeing Q And what, if any, things have a negative or bad effect on your own emotions or mental health and wellbeing?

Wea

ther

Wor

k / w

orki

ng

patt

erns

/ ha

ving

too

muc

h w

ork

Not

eno

ugh

mon

ey /

low

in

com

e

Illn

ess (

phys

ical

)

Prob

lem

s in

rela

tions

hip

with

par

tner

/ fa

mily

/ fr

iend

s

Illn

ess i

n th

e fa

mily

/ or

fr

iend

s

Base: All respondents % % % % % %

All (1,216) 13 12 10 8 7 6 Men (578) 9 14 11 7 7 3 Women (638) 16 9 10 10 7 8

16-24 (108) 8 10 10 5 10 5

35-34 (164) 16 23 18 4 10 4

35-44 (225) 12 17 18 11 5 9

45-54 (196) 11 16 12 7 9 6

55-59 (110) 15 8 6 7 3 7

60-64 (116) 17 4 1 12 11 6

65-74 (177) 13 - 3 7 4 6

75+ (120) 13 - - 18 3 4

Household income of less than £5,200 (71) 12 4 7 5 7 1


11 29 11 6 7 10

Easy to manage on household income (630) 13 14 8 7 7 6 Difficult to manage on household income (156)

11 9 21 9 9 4

SIMD least deprived area (band 5) (238) 11 21 9 8 7 6 SIMD most deprived area (band 1) (209) 15 6 12 8 5 5

Source: Ipsos-MORI

5.21 Previous research has shown that the absence of positive influences on mental wellbeing, rather than the presence of negative influences, is crucial in predicting suicidal behaviour15. Accordingly, analysis was undertaken to explore whether there was a relationship between the number of positive and negative influences mentioned by

15 O’Connor et al, 2007. Predicting Short-term Outcome in Wellbeing Following Suicidal Behaviour: The Conjoint Effects of Social Perfectionism and Positive Future Thinking. Behaviour Research and Therapy 45, 1543-1555.

50

respondents and their mental health as measured by their responses to the GHQ12 and WEMWBS. In the event, no such relationship was found to exist. The absence of any relationship may have been because the questions on positive and negative influences allowed open responses rather than forced, closed responses. A fuller discussion of the analysis is provide in Annex I. Self assessed control over factors affecting mental health 5.22 Respondents were asked how much control they felt they had over things which affect their mental health and wellbeing. Around two thirds (65%) felt they had a good deal or complete control, compared with 8% who felt they had little or no control. Although there has been some variation over time in the level of control people feel they have over factors that affect their mental health (see figure 5.1), a comparison of the mean scores across the three waves of the surveys uncovers no significant differences. Figure 5.1: Levels of control over mental health. Trend since 2002

Q Thinking about all those things that might affect your own emotions or mental health and well-being , how much control, if any, do you feel you

have over them?

2

5

21

57

14

2

7

23

51

15

2

6

25

48

17

0 10 20 30 40 50 60

No control at all

A little control

Some control

A good deal of control

Complete control

% agree

200620042002

Base: All respondents 2002 (1,381); 2004 (1,401); 2006 (1,216) Source: Ipsos MORI

51

Table 5.5: Perceived levels of control over factors affecting mental health Q Thinking about all those things that might affect your own emotions or mental health and wellbeing, how much control, if any, do you feel you have over them?

Complete control

A good deal of control

Some control

A little control

No control at all

Don’t know


All (1,216) 17 48 25 6 2 2

Male (529) 18 49 22 6 2 3

Female (687) 16 47 28 6 2 2

16-24 (108) 24 52 16 2 1 5

25-34 (164) 12 54 24 7 * 2

35-44 (164) 14 50 29 5 2 1

45-54 (225) 17 38 36 6 1 2

55-59 (196) 14 47 27 6 5 *

60-64 (116) 15 51 22 9 1 1

65-74 (177) 21 48 17 9 2 2

75+ (120) 21 39 25 6 3 5

Easy to manage on household income (630)

19 52 21 5 1 2

Difficult to manage on household income (156)

13 35 32 14 5 1


20 30 34 11 2 3


9 60 21 6 2 2

Experienced a mental health problem of their own (384)

17 39 29 10 4 1

No experience of mental health problems (298)

20 54 21 3 1 2

Low mental ill-health score (379) 20 47 26 5 * 2


Good mental wellbeing (133) 39 52 6 2 - 2

Average mental wellbeing (716) 14 51 29 5 1 1

Poor mental wellbeing (133) 8 33 32 17 7 4

Good or very good general health (882)

18 52 24 4 1 2

Bad or very bad general health (93)

16 26 32 20 6 1

Source: Ipsos MORI

52

5.23 There were no differences between men and women in terms of the level of control they feel they have. And although it was mainly among women that the sense of being in control decreased between 2002 and 2004 (from 70% in 2002 to 62% in 2004), this figure has remained static in the present survey. A comparison of the mean scores for men and women across the three waves confirms this pattern. 5.24 There was significant variation by age group in the 2006 survey however; respondents aged 16-24 were more likely to feel in control than most other age groups, and especially those aged 45-55 and 65+. The 16-24 age group in 2004 also reported higher levels of control than the other age groups. It may be that the factors which young people most commonly mention are having an effect on their mental health and wellbeing – namely, work and having enough money – are easier to control or, at least tolerate, than the factors mentioned by older people, that is, illness and weather. 5.25 People with a household income of over £36,400 were more likely to feel in control of factors affecting their mental health than those with an income of less than £5,200. Similarly, those who found it easy to manage on their income were more likely to feel in control than those who found it difficult. If we relate these findings back to the factors that respondents with higher and lower incomes identified as having an influence on their mental health and wellbeing, it may be the case that contact with friends and family and work pattern are easier to control than not having enough money. On the other hand, it could be the case that people who are better off are likely to feel more in control because they have fewer concerns about how to support basic day-to-day living (e.g. food and utilities bills) and can afford access to services that promote a more relaxed lifestyle, for example, holidays and alternative therapies. 5.26 People who rated their general health as bad or very bad tended to feel less in control than those who rated it as good or very good. Similarly, those who said that they had experienced a mental health problem themselves, or who had a high mental ill-health score, were more likely to feel they lacked control than other respondents. Finally, those with poor or average mental wellbeing were less likely to feel in control than those with good mental wellbeing (table 5.7). 5.27 Mediation analysis was undertaken to explore whether and to what extent, the relationship between socio-economic status and mental health, highlighted elsewhere in this report, is mediated by perceptions of control (over factors that influence mental well being). Mediational analysis is helpful in this context, as it allows us to examine what factors, if any, link socio-economic status to mental health. With respect to perceptions of control, it may be that if you are from a lower socio-economic background that this is associated with lower perceptions of control which, in turn, are associated with poor mental health. The analysis drew on four individual measures of socio-economic status (SES), namely:

• area deprivation (as measured by SIMD and derived from postcode – 5 categories);

• annual income (5 bands: up to £5,200; £5,200- £15,600; £15,600-£26,000; £26,000-£36,000; and over £36,000);

• employment status (working or not working);

• highest professional qualification (4 bands: SLC, O Grade/ Standard Grade or equivalent; GSVQ/ SVQ/ SCOTVEC or equivalent; SEC Highers, A-levels, or equivalent); and first degree, higher degree, professional qualifications or equivalent).

53

5.28 A composite SES measure, comprising all 4 variables was also added to the analysis. The mental health indicators used in the analysis were the GHQ12 and WEMWBS. 5.29 Looking at the results of the analysis, perceptions of control were found to have a substantial mediating effect on the relationship between employment status and mental health - although this effect was only significant in respect to the WEMWBS measure of mental health, not the GHQ12 measure. In this case, people in paid employment reported higher perceptions of control (over factors that influence mental well being) which were in turn associated with more positive mental wellbeing. No other mediating effects were uncovered.

54

CHAPTER SIX: EXPERIENCE OF MENTAL HEALTH PROBLEMS 6.1 This chapter focuses on respondents’ personal experience of mental ill-health, both through having experienced a mental health problem themselves and through the experiences of people close to them (experience by proxy). The chapter considers the social consequences of mental ill-health from the perspective of those with direct personal experience. It also looks at issues relating to recovery from mental ill-health, including factors which are thought to promote and hinder recovery, what recovery means to people experiencing mental health problems and the messages about recovery they have received from professionals and those close to them. Experience of mental health problems in someone close 6.2 Around three in five respondents (61%) said that someone close to them had experienced a mental health problem, consistent with the findings from the 2004 survey (62%). This figure is lower than the 68% obtained from a 2005 survey of public attitudes to mental health in Ireland (Mental Health Ireland, 2005) but this may partly reflect differences in the question wording used in the two surveys. 6.3 Results varied as a function of age, with those aged 75 years and over being less likely than all other age groups to say someone close to them had experienced a mental health problem. On the one hand, this is surprising as it might be expected that older people would have greater experience of mental ill-health because of the length of time they have lived – and because people in their peer group are at greater risk of dementia. On the other hand, it may be that older people are less aware than younger groups of what constitutes a mental health problem today or more likely to stigmatise mental ill-health which in turn may lead them to disassociate themselves from people suffering from such problems, or to redefine mental ill-health in terms they find less stigmatising. Findings reported in chapter 7 (below), lend credence to this interpretation. 6.4 Recent research on income-related inequality in mental health has highlighted a correlation between lower income and higher prevalence of mental health problems (see, for example, Mangalore et al, 2007). The present survey reinforces these findings: people who found it difficult to manage on their income were more likely than those who found it easy to manage to say someone close to them has suffered from a mental health problem (71% compared with 58%). Proxy experience of a problem was also higher among those with high mental ill-health scores than among those with low scores (77% compared with 60%). 6.5 Respondents were presented with a list of specific mental health problems and asked if anyone close to them had ever experienced any of these. As in previous waves of the survey, the conditions that the respondents most commonly said someone close to them had experienced were depression (45%), panic attacks (23%) and Alzheimer’s disease/Dementia (19%), followed by nervous breakdown (16%), anxiety disorder (15%), post-natal depression (15%) and severe stress (15%). Three of these conditions - panic attacks, anxiety disorder and severe stress - come under the clinical heading of neurotic and stress related disorders, as do phobias and excessive compulsive disorder (mentioned by 8% and 7% respectively). If all of these conditions are collapsed into one response category, a total of 37% of respondents have proxy experience of a neurotic or stress-related disorder.

55

6.6 Table 6.1 shows the results by key sub-groups. There were few differences by gender but age was a significant variable - people aged 25-34 were consistently more likely than those aged 75 or over to claim proxy experience of specific conditions. Again, these differences may reflect growing societal awareness and understanding of mental-ill health over time, as well as changes in the range of conditions classified as mental health problems. 6.7 For each of the specific problems listed, proxy experience was also more prevalent among respondents who found it difficult to manage on their income than among those who found it easy to manage.

56

Table 6.1: Experience of mental health problems in someone close. Q From what you know, has anyone close to you ever been told by a doctor or other health professional that they had one or other of these kinds of specific mental health problem?

2004 All Male Female Aged

75+

Aged

25-34

Difficult to

manage on

income

Easy to manage

on income

Base: All respondents 1,401 1,216 529 687 120 164 630 156

% % % % % % % %

Depression 48 45 45 46 14 57 54 45

Panic attacks 26 23 20 25 5 35 32 21

Alzheimer’s Disease/dementia

20 19 18 20 20 16 19 21

Nervous breakdown 18 16 15 16 4 17 22 15

Anxiety disorder 13 15 15 14 3 21 27 13

Post-natal depression 16 15 12 18 2 23 20 13

Severe stress 19 15 15 15 5 23 22 15

Eating disorder (anorexia, bulimia)

10 11 9 12 * 18 17 11

Manic depression (bipolar affective disorder)

9 10 9 12 2 13 18 10

Self harm 8 9 10 8 - 12 16 8

Phobias (e.g. agoraphobia) 7 8 8 7 2 9 13 8

Schizophrenia 7 8 8 9 5 8 15 8

Obsessive compulsive behaviour/disorder

6 7 7 7 1 13 9 7

Post-traumatic stress disorder n/a 6 6 6 1 8 11 6

Personality disorder 3 5 5 4 1 8 11 3

Any of these 70 69 68 70 40 82 78 71

None of these 29 27 28 27 50 16 19 26

Don’t know/refused. 1 4 4 3 9 1 3 3

Source: Ipsos MORI

Personal experience of mental health problems 6.8 Just over 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%) but higher than that recorded in the 2005 Mental Health Ireland survey (10%) and the 2006 Health Protection Agency Northern Ireland (HPA NI) survey (15%). Again, this difference may be due to question wording or the methodology used. For example, the

57

Mental Health Ireland survey was conducted over the telephone which may have resulted in different rates of participation or high item refusal. 6.9 The specific mental health problems most commonly experienced by respondents were depression (16%), followed by panic attacks (8%), severe stress (4%) and anxiety disorder (4%). However, if we collapse all of the neurotic and stress-related disorders into one category, as in the case of proxy experience of mental ill-health, we find that a total of 12% of respondents have had personal experience of such a disorder 6.10 As illustrated in table 6.2, women were more likely than men to say they had experienced any of the mental health problems listed (32% compared with 24%) and women aged 35-54 were the most likely to do so (36%). Women were also more likely than men to say they had experienced depression (19% compared with 14%). The findings reported here are similar to the prevalence of mental health problems in the UK reported by the Mental Health Foundation (2003). Women were more likely to report significant symptoms of depression and anxiety (18%) compared with men (12%) (Mental Health Foundation 2003). 6.11 The highest and lowest income groups were more likely to have experienced a mental health problem than middle income groups. At the same time, however, the lowest income group was considerably more likely than the highest income group to have experience of depression. Reflecting these difference, people who found it difficult to manage on their income were twice as likely as those who found it easy to manage to have had a mental health problem and to have experience of depression specifically. 6.12 People with high mental ill-health scores were more likely than those with low scores to have personal experience of mental ill-health, while those with poor mental wellbeing were more likely to report such experience than those with good mental wellbeing. And, people who felt they had little or no control over factors affecting their mental wellbeing were more likely to have experienced a problem than those who felt they had at lest a good deal of control. There was also significant variation by respondents’ general health status. Those who said their general health was “bad” were more likely than those who felt they had “good” general health to say they had experienced one or more of the mental health problems listed in the table below (59% compared with 23%). The latter finding is consistent with other research conducted in recent years. For example, the 2000 Adult Psychiatric Morbidity Study (Singleton et al, 2000) found that having a neurotic disorder substantially increased the likelihood of reporting one or more physical complaints. Of course, it is difficult to know whether certain mental health problems make people more susceptible to physical illness or whether having a physical illness makes people more susceptible to mental health problems. However, there is increasing evidence that being depressed or stressed can make people more susceptible to illnesses such as heart disease and cancers (see, for example, Stansfeld and Marmot, 2001). 6.13 Looking at geographical variation, people in the most rural areas were more likely than those in more urban areas to have experienced a problem, although there was no equivalent variation by NHS board area.

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Table 6.2: Personal experience of a mental health problem Q Have you ever been told by a doctor or other health professional that you personally have had one or other of these kinds of specific mental health problems?

Any Depression Panic attacks

Severe stress

Anxiety disorder

None of these

Base: All respondents Row percentages % % % % % %

All (1,216) 28 16 8 4 4 70

2004 (1,401) 26 17 7 6 4 73

Male (529) 24 14 6 4 3 74

Female (687) 32 19 10 5 4 67

Male aged 16-34 (128) 21 15 4 1 3 76

Female aged 16-34 (144) 28 12 8 3 3 69

Male aged 35-54 (179) 29 17 8 7 4 69

Female aged 35-54 (242) 36 23 10 6 4 63

Male aged 55+ (222) 21 9 7 4 3 77

Female aged 55+ (301) 30 20 10 5 5 69

Annual household income less than £5,200

45 36 14 10 11 55

Annual household income between £15,600 and £26,000

24 15 7 4 4 75

Annual household income £36,400 or more

38 21 11 7 5 62

Easy to manage on income (630) 26 14 6 3 4 74

Difficult to mange on income (156)

51 36 17 13 12 48

Most urban (480) 28 16 8 4 4 69

Most rural (84) 32 20 15 9 7 65

Complete/good deal of control (767)

24 13 7 3 3 75

Little/no Control (104) 51 33 16 13 12 47

Good mental wellbeing (133) 14 8 3 2 2 84

Average mental wellbeing (716) 28 15 8 4 4 71

Low mental wellbeing (133) 44 32 20 14 12 55

Low mental ill-health score (379) 22 12 6 2 4 77


General health good or very good (882)

23 12 6 3 2 75

General health bad or very bad (93)

59 46 22 18 16 39

Source: Ipsos MORI

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Telling others about mental health problems 6.14 A new question was introduced in 2006. 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 their problem. Overall, 86% said they had done so, with the majority (80%) saying they had told family and friends. One in five said they had told their boss or manager at work (20%) or other colleagues at work (20%), while smaller proportions had told other people they don’t know well (6%) or a tutor or member of staff at college or university (5%). Fifteen per cent said they had told no-one about their mental health problem (figure 6.1 below). 6.15 Although not directly comparable, the Mind Out for Mental Health16 survey in the UK found that 74% of job applicants with mental health problems did not disclose their condition in application forms and 52% concealed their mental health problems for fear of losing their job. A similar pattern of findings was evident in Ireland also. A survey conducted in 2005 by Workway17 found that two thirds of those surveyed felt unable to disclose their mental health problems at interview and 4 in 10 had not disclosed their mental health problems to anyone in the workplace. Figure 6.1: Disclosure of mental health problems

Q Have you told anyone about your mental health problem, apart from your doctor or any other health professionals?

15

5

6

20

20

80

0 10 20 30 40 50 60 70 80 90

No. I have told no-one

Yes, I have told a tutor/member of staff atcollege/university/other course

Yes, I have told other people I don't know well

Yes, I have told other colleagues at work

Yes, I have told my manager/boss at work

Yes, I have told family and/or friends

%Base:All who have personally experienced a mental health problem (384) Source: Ipsos MORI

6.16 Sub-group findings cannot be reported for this question because of the small base sizes. Further, as this question was only asked in the 2006 survey it has not been possible to

16 The Mind Out for Mental Health survey was commissioned by UK Department of Health in association with the Mental Health Foundation, Mind and the National Schizophrenia Fellowship (see mind.org.uk) 17 Mental Health and Employment survey: Dublin: Workway.

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combine the data sets from all three waves to allow for more robust analysis, as has been done elsewhere in this chapter. The social impact of mental ill-health 6.17 In the 2004 survey, 64% of those who had personally experienced mental ill-health had not experienced any difficulties in terms of other people’s attitudes towards their problem. This figure has risen over ten percentage points to 75% in the current survey. Among the minority who have experienced difficulties in terms of other people’s attitudes, the most common experiences remain being discouraged from participating in social events (11%), discrimination at work (5%) and being refused a job (5%) as table 6.3 shows. While the proportions mentioning each of these are fairly consistent with 2004, there has been a decrease in the percentage saying they have experienced verbal abuse in public.

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Table 6.3: Social impact of mental ill-health. Data from 2002, 2004 and 2006

Q Have you experienced any of the following as a result of other people’s attitudes towards your mental health problem(s)?

Percent Experienced

Base: All who have personally experienced a mental health problem

2002 (440 )

2004 (377 )

2006 (384)

% % %

Discouraged from participating in social events† 12 15 11

Experienced discrimination at work 7 6 5

Been refused a job 6 4 5

Verbally abused within the family 7 6 4

Discouraged from taking part in community life† 4 6 4

Discouraged from going on holiday† 3 4 4

Been overlooked/refused for promotion 4 5 3

Physically abused within the family 4 4 2

Verbally abused in public 8 5 2

Discouraged from participating in children’s school based activities†

1 2 2

Physically abused in public 3 2 *

Graffiti or rubbish targeted at the home 1 1 1

Other 2 2 2

None of these 68 64 75

Don’t know 1 * *

Source: Ipsos MORI† Wording of codes changed from 2004 questionnaire 6.18 The data for the three surveys were combined to allow for robust sub-group analyses. As table 6.4 shows, a number of interesting findings emerged. In particular, men were more likely than women to say that they had been refused a job because of other people’s attitudes towards their mental health problem, while women were more likely to say they had not experienced any such forms of stigma. This may be because people are less comfortable about interacting with a man who has a mental health problem than with a women who has the same problem– a hypothesis that is considered further in chapter 8. 6.19 As a whole, the younger age groups were more likely than older age groups to have experienced the difficulties listed. There are a number of possible explanations for this difference. It may be that older people are simply less likely to have revealed their problem to others for fear of stigmatisation. Alternatively, it may be that younger people move in a wider range of social environments than older groups - whether this be in terms of education/ employment or other social situations - and in the process are exposed to a wider range of people and thus perspectives on mental ill-health.

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6.20 There was further variation by income, with lower income groups more likely than those on a higher income to have experienced some form of stigma. Similarly, people who had trouble managing on their income were more likely to have experienced difficulties than those who found it easy to manage. In part, these differences may reflect the contrasting social milieus in which better and less well off respondents move. As is reported in later chapters, more economically advantaged segments of society tend to hold more liberal attitudes toward mental ill-health than more disadvantaged groups. Table 6.4: Social impact of mental ill-health

Q Have you experienced any of the following as a result of other people’s attitudes towards your mental health problems?

Discouraged from

participating in social events

Experienced discrimination

at work

Been refused a job

None of these

Base: All respondents % % % %Row percentages

All (1,207) 13 6 5 69

Male (400) 14 7 7 65

Female (807) 13 6 4 71

Male aged 16-34 (73) 15 4 13 61

Female aged 16-34 (208) 19 10 7 61

Male aged 35-54 (119) 14 7 5 64

Female aged 35-54 (141) 12 5 4 72

Male aged 55+ (443) 11 11 3 73

Female aged 55+ (223) 9 4 1 77

Easy to manage on income (460)

10 4 3 76

Difficult to mange on income (299)

18 8 10 58


24 5 9 56


8 4 4 81

Source: Ipsos MORI

6.21 Respondents to the 2006 survey who said they had experienced a mental health problem were 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. This is significantly higher than the proportion who had actually been discouraged from participating in a social event, which suggests that self-stigmatisation is a major issue that requires to be addressed. It is the anticipation of failure or rejection which limits, in part, an individual’s behaviour. The implications of self-stigmatisation are considerable and can impede recovery. Indeed, a recent study of patients diagnosed with schizophrenia found that

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self-stigmatization undermined self-efficacy and empowerment which was associated with poorer quality of life and depression (Vauth et al., 2007). These findings suggest that more work is required to change an individual’s thoughts and attitudes to facilitate recovery from mental health problems. Recovery from mental health problems18 6.22 Promoting and supporting recovery is one of the four key aims of the Scottish Executive's National Programme for Improving Mental Health and Wellbeing. The Scottish Recovery Network (SRN) was launched in late 2004 as part of this Programme. The main aims of the SRN are 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. In the 2004 survey, a series of questions were introduced to investigate the public’s views on recovery and to provide a baseline measure to later track the impact of the SRN’s work across communities. The questions focused on factors important in supporting recovery and key signs of recovery. For the 2006 survey, the questions were refined slightly. They were also supplemented with additional items on the factors that hindered recovery and messages of recovery received from other people. Accordingly, any comparison between the two sets of results should be treated with due caution. As in 2004, these questions were only asked of those who said they had experienced a mental health problem. 6.23 The factors that respondents felt had been most important in supporting their recovery were support from family or friends (56%), medication (35%), developing their own coping strategies (30%), having belief in themselves (27%), and other forms of treatment or therapy such as psychology, counselling, alternative treatments and support groups (20%) (table 6.5). The rank ordering of these factors is broadly consistent with the comparable 2004 findings, although the introduction of new items to the 2006 questionnaire means that the absolute levels of response differ across the two surveys. The emphasis on support from family and friends, self belief and personal coping strategies is also in line with findings from a recent narrative research study undertaken by SRN (Brown and Kandirikirira, http://www.scottishrecovery.net/content/default.asp?page=s5_4). 6.24 There was a small amount of sub-group variation in the findings. Women were more likely than men to mention medication as a factor promoting their recovery (41% versus 25%) and young women were more likely than all other groups to mention support from family and friends (78% versus for example 48% of women aged 35 to 54 years). Respondents with the highest educational qualification were among those most likely to mention ‘developing my own coping strategies’ (43% compared with 12% of those with no qualifications).

18 For the Scottish Recovery Network, recovery is not simply about the absence of symptoms, but about giving people the tools to become active participants in their own health care and having a belief, drive and commitment to the principle that people can and do recover control in their lives, even where they may continue to live with ongoing symptoms

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Table 6.5: Factors important in supporting recovery

Q Thinking again about the mental health problem(s) you have experienced, which two or three, if any, of the following were most important in supporting your recovery?

2004 2006

Base: All who have experience of a mental health problem (377) %

(384) %

Support from family or friends 76 56

Medication 38 35

Developing my own coping strategies n/a 30

Having belief in myself n/a 27

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

29 20

Having others believe in me n/a 12

Support from people with a similar experience 14 11

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

21 11

Support from colleagues/work 18 8

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

6 8

Having a chance to contribute and be valued n/a 2

Other 3 6

I don’t believe myself to be in recovery 2 *

None of these 4 3

Don’t know * *

Source: Ipsos MORI†Wording of code changed from 2004 6.25 Factor analysis was conducted to identify related recovery strategies. The analysis provided a two-factor solution, with one factor (‘factor 1’) grouping strategies that mainly related to the extent to which people rely on support from others, and the other (‘factor 2’) relating mainly to more action-orientated strategies that could be employed without the help of others (table 6.6 below). 6.26 Looking at factor 1 (support strategies) in more detail, two sub-factors were observed. The first comprised external support, including ‘support from people with a similar experience’, ‘support from colleagues/work’, ‘having others believe in me’ and ‘support from family/friends’. The second was ‘developing my own coping strategies’ - a more internal coping strategy. Respondents who scored highly on factor 1 tended to mention the various forms of external support a lot, while those with a low score tended not to mention external

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forms of support and/or to mention ‘developing my own coping strategies’ instead. So what is particularly noteworthy here is that, within this factor, people usually reported engaging in external or internal strategies not both. It is also of interest that ‘developing my own coping strategies’ loaded on factor 1 and not factor 2. 6.27 Within factor 2 (action orientated strategies) there was a clear distinction between behaviour-driven strategies that tackle mental ill-health directly, and more indirect strategies. The behaviour driven strategies included ‘other forms of treatment/therapy’, ‘medication’ and ‘finding out more about mental health’. The indirect strategies included ‘self belief’, ‘having something worthwhile to do during the day’ and ‘having a chance to contribute and be valued’. Respondent who scored highly on factor 2 tended to mention the behaviour driven strategies and not the indirect strategies. 6.28 To explore the extent of any relationship between respondents’ recovery strategies and their mental health, their scores on the factors were correlated against their GHQ12 and WEMWBS scores. WEMWBS showed a relatively strong negative correlation with factor 2, that is, there was a tendency for those with good mental wellbeing to employ the more indirect recovery strategies, rather than the more behavioural driven strategies. Looking more closely at how this factor is constructed, the specific strategy that is by far the most strongly correlated with WEMWBS is, ‘having belief in myself’. Thus it may be said that, above all else, good mental wellbeing among those recovering from a problem, is associated with self belief or mastery. This finding is consistent with research within the psychological domain which highlights the central importance of self-belief and self-efficacy in the aetiology and maintenance of mental and physical health (e.g, Mitchell, 1998; Higgins et al., 1992; Stepney & Davis, 2004). Table 6.6: Factor analysis 2 factor solution

Factor Composition 1 -Support from people with a similar experience

-Support from colleagues/work -Having others believe in me -Developing my own coping strategies -Support from family or friends

2 -Having belief in myself -Other forms of treatment/therapy -Medication -Finding out more about mental health -Having something worthwhile to do during the day -Having a chance to contribute and be valued

6.29 In terms of the factors which had most hindered their recovery, around one in five respondents (19%) said ‘not acknowledging I had a problem’, ‘continuing to experience problems’ (17%) and ‘not understanding what was going on’ (17%). The prominence of the latter factor is consistent with the finding from the SRN narrative research which revealed that learning more about mental health and wellbeing can be a key step towards recovery for many people. 6.30 A third (34%) said that none of the factors presented had hindered their recovery. Given that this figure is relatively high, it may be that there are factors, over and above those

66

listed in the question, which contribute to recovery. However, no further information was collected in this run of the survey (table 6.7). Table 6.7: Factors hindering recovery

Q And what factors, if any, have hindered your recovery?

Base: All who have experience of a mental health problem (384) %

Not acknowledging I had a problem 19

Continuing to experience symptoms 17

Not understanding what was going on 17

Negative attitudes of people around me 13

Not feeling able to tell people about my mental health problem 12

Lack of support or understanding from family or friends 9

Not being able to access appropriate services or treatment 7

Not getting the right medication 6

Lack of support or understanding from colleagues/work 5

Lack of access to employment, education or training opportunities 4

Other 6

None of these 34

Don’t know 2

Any 64

Source: Ipsos MORI 6.31 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’, mentioned by 32% and 20% respectively. The proportion mentioning ‘fewer symptoms’ is relatively low at 9%. Consistent with the conception of recovery detailed in the SRN narrative research, these results suggest that what is important to people is not an absence or remission of symptoms but being able to go about their day to day life, despite symptoms (Table 6.8).

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Table 6.8: Meanings of recovery

Q What does recovery mean to you?

Base: All who have experience of a mental health problem (384)

%

Getting back to normal 49

Taking charge of my life again 38

Feeling able to cope in general 32

Having a satisfying and fulfilling life 20

Fewer symptoms 9

Getting involved in activities I enjoy 8

Feeling more able to socialise 7

Getting back to work 6

To feel positive / happy / confident again 6

Getting more sleep 6

No longer needing treatment or services (including medication) 5

Don’t know 2

Source: Ipsos MORI 6.32 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 (66%) received a positive message from professionals while three quarters (76%) did so from people around them (figures 6.2 and 6.3 below). 6.33 There was a correlation between the valence of recovery messages respondents had received and their mental health. Specifically, those who had received positive messages were more likely to have a low mental ill-health score and good mental wellbeing than those who had received negative messages. This reinforces findings from the SRN narrative research which found that if a message of hope is delivered at the time of diagnosis and treatment, this hope is carried by the patient and can be a catalyst for getting better (Brown & Kandirikirira, 2006).

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Figure 6.2: Message of recovery from professionals

Q To what extent have the professionals you have come into contact with (nurses, doctors, support workers etc.) given you a positive or negative

message about your recovery?

Completely positive33%

Mainly positive33%

Mixed16%

Mainly negative2%

Completely negative1%

Don't know/not s tated15%

Base:All who have personally experienced a mental health problem (384) Source: Ipsos MORI

Figure 6.3: Message of recovery from people close

Q To what extent have the people around you (family, friends, colleagues, carers etc.) given you a positive or negative message about

your recovery?

Completely positive40%

Mainly positive36%

Mixed14%

Mainly negative1%

Don't know/not s tated

9%

Base:All who have personally experienced a mental health problem (384) Source: Ipsos MORI

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CHAPTER SEVEN: ATTITUDES TOWARDS MENTAL HEALTH PROBLEMS 7.1 This chapter considers public attitudes towards mental ill-health with a particular emphasis on changes in attitudes over the three waves of the survey. It also considers the perceived prevalence of mental ill-health in Scotland. Attitudes towards mental ill-health 7.2 As noted in Chapter 1, one of the key aims of the National Programme for Improving Mental Health and Wellbeing is to promote positive changes in attitudes towards people with mental health problems. To help measure progress towards this aim, respondents in all three waves of the research have been presented with a number of attitudinal statements relating to mental health and asked to indicate whether they agreed or disagreed with each statement. 7.3 For the most part, attitudes appear to have remained fairly consistent since the time of the last survey. Thus almost all (97%) respondents continue to agree that ‘anyone can suffer from a mental health problem’, 85% think people with mental health problems should have the same rights as anyone else, 46% agree that ‘the majority of people with mental health problems recover’ and 40% agree that ‘people are generally caring any sympathetic to people with mental health problems’. The percentages of respondents agreeing with some of the more negative statements also show little change since 2004: 17% say ‘I would find it hard to talk to someone with a mental health problem’, and 4% say ‘people with mental health problems are largely to blame for their own condition’ (table 7.1 below). 7.4 Notwithstanding these continuities, there also appear to have been some significant shifts in attitudes since 2004. First, 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. This is encouraging and suggests that the Scottish Executive’s work on tackling the stigma and discrimination associated with mental health problems, especially through the ‘see me’ anti-stigma campaign, may be having a real impact on the way people think about mental health problems. 7.5 At the same time, however, the proportion agreeing that the public should be better protected from people with mental health problems (32%) has returned to the level recorded in 2002 (35%), despite a significant decrease in 2004 (24%). This may reflect events which took place at the time the survey was being conducted. Around the time of the data collection there was considerable media interest around the issues of secure care, violence and systems failures. Although it is beyond the scope of the present study to conduct a in-depth analysis of the media representation of mental health issues, we have reviewed a selection of the print media cuttings from across Scotland during the period of data collection, nationally and locally, broadsheet and tabloid. Across this non-systematic review of the cuttings, there were many somewhat negative media representations of mental health, secure care and the risk of mental health patients to the community. Headlines included “Dangerous offenders in bid to use loophole to win freedom from high-security units”, “High-risk killers on the loose in Scotland and “The blunders that let mental patient roam free to kill”. No review of cuttings

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was carried out in 2002 or 2004, so it is not possible to say whether there was an absence of such negative representations during these earlier waves of the survey. 7.6 However, it is important to bear in mind that the increase in the proportion saying that the public should be better protected from people with mental health problems has not been reflected in a more general negative shift in attitudes towards people with mental health problems. Most notably, there has been no corresponding increase in the proportion of people agreeing with the statement that ‘people with mental health problems are often dangerous’.

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Table 7.1: Attitudes to mental ill-health, by survey

Q. I’m now going to read out some things people have said about mental health problems. Taking your answer from this card, I’d like you to tell me how much you agree or disagree with each of these statements

% agreeing

2002 2004 2006

Base: (1,381) (1,401) (1,216)

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

50 45 41

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

35 24 32

Anyone can suffer from a mental health problem

98 97 97

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

20 15 17

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

36 39 40

People with mental health problems are often dangerous

32 15 16

The majority of people with mental health problems recover

50 46 46

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

88 88 85

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

7 6 4

Source: Ipsos MORI

7.7 In the Health Protection Agency Northern Ireland (HPA NI) survey cited earlier, respondents were similarly presented with the attitudes statements listed above. As table 7.2 below shows, there is broad consistency in the results for the two surveys but more people in Northern Ireland agree that if they were experiencing a mental health problem they wouldn’t

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want people knowing about it, that the public should be better protected from people with a mental health problem and that people with mental health problems are often dangerous. Indeed, the Northern Irish results are more consistent with findings from 2002 Scottish survey. In part this may reflect the fact that there has not yet been a mental health anti-stigma and discrimination campaign in Northern Ireland akin to ‘see me…’ Table 7.2: Attitudes towards mental ill-health in Scotland and Northern Ireland

Q. I’m now going to read out some things people have said about mental health problems. Taking your answer from this card, I’d like you to tell me how much you agree or disagree with each of these statements ‘Well?

What do you think?’

2006

HPA NI 2006

Base: (1,216) %

(1,013) %


41 54


32 41


97 98


17 19


40 34


16 26


46 43


85 91


4 6

Source: Ipsos MORI and HPA NI

7.8 While women were more likely than men to disagree that they would find it hard to talk to someone with a mental health problem (73% versus 64%), men were more likely to feel that people are generally caring and sympathetic towards people with mental health problems (43% versus 36%). Young women (aged 16-24 years) were more likely than their

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male counterparts to disagree that if they were suffering from a mental health problem they wouldn’t want people knowing about it (45% versus 31%). 7.9 As table 7.3 (below) illustrates, respondents who were aged 75 and over or had lower or no educational qualifications were among those most likely to agree that the public should be better protected from people with mental health problems and that people with mental health problems are often dangerous. 7.10 It is interesting to note that people with the highest educational qualifications were much more likely than the next most qualified group to say that if they had a mental health problem, they wouldn’t want people knowing about it. It may be that the former group might feel their higher professional status would be threatened if a mental health problem were revealed. Or, the difference may simply be a reflection of the relative affluence of more and less educated groups. Those with higher education qualifications are likely to live in less deprived parts of the country where mental ill-health tends to be less prevalent than in more deprived areas, and possibly less talked-about as a consequence. 7.11 Other findings cast doubt on this latter hypothesis, however. Analysis by area deprivation reveals that people living in the most deprived areas were more likely than those in the least deprived areas to agree that they would find it hard to talk to someone with a mental health problem (24% versus 14%), that the public should be better protected from people with mental health problems (40% versus 31%), and that people with mental health problems are largely to blame for their own condition (8% versus 3%). Those in the least deprived areas were significantly more likely than those in other areas to disagree that people with mental health problems are often dangerous (68% versus 56% of those in the most deprived areas). Clearly then, the higher incidence of mental ill-health in more deprived areas does not result in higher tolerance of mental ill-health in those areas. It may be that those in less deprived areas have lower understanding of mental ill-health problems (or more experience of neighbourhood disruption caused by such problems) which makes them fearful of those who suffer in this way.

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Table 7.3: Attitudes towards mental ill-health, by age and education Q I’d like you to tell me how much you agree or disagree with each of these statements…

% agreeing

Age group Educational qualifications

16-2

4

45-5

4

75+

Firs

t deg

ree,

hig

her

degr

ee/p

rofe

ssio

nal

qual

ifica

tion/

equi

vale

nt

SEC

hig

her

grad

e or

eq

uiva

lent

O g

rade

or

equi

vale

nt

Scho

ol le

avin

g ce

rtifi

cate

or

equ

ival

ent

No

qual

ifica

tions

Base: (108) (196) (120) (118) (203) (215) (385) (295)

% % % % % % % %

If I were suffering from mental health problems, I wouldn’t want people knowing about it

33 39 38 48 36 40 37 40


22 33 52 25 32 30 50 37

Anyone can suffer from mental health problems

95 98 94 97 98 98 93 96


13 14 23 12 14 16 19 25

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

55 35 50 23 44 46 47 51


10 15 31 9 13 13 24 26

The majority of people with mental heath problems recover

44 55 35 47 38 47 48 48


90 89 85 86

89 84 77 84


5 3 5 2 3 3 6 7

Source: Ipsos MORI

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7.12 There was further variation in people’s attitudes according to whether they had any experience of mental ill-health. As table 7.4 below shows, those with no proxy or personal experience of mental ill-health were more likely to agree that the public should be better protected from people with mental health problems, that they would find it hard to talk to someone with a mental health problem and that people are generally caring and sympathetic towards people with mental health problems. Conversely, respondents with experience of mental ill-health were more likely than those with no experience to disagree that people with mental health problems are dangerous and to agree that the majority of people with mental health problems recover. There was no variation by respondents’ mental ill-health scores but people with poor mental wellbeing were more likely than those with good mental wellbeing to say they would find it hard to talk to someone with mental health problems (33% versus 12%). This is consistent with the finding, discussed in chapter 4, that people with good mental wellbeing tended to have higher levels of social engagement than those with poor mental wellbeing. Table 7.4: Attitudes to mental ill-health, by experience of mental health problems

Q. I’m now going to read out some things people have said about mental health problems. Taking your answer from this card, I’d like you to tell me how much you agree or disagree with each of these statements

Personal experience

Proxy experience

No experience

Base: (384) %

(870) %

(298) %

If I were suffering from mental health problems, I wouldn’t want people knowing about it

45 43 47

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

28 29 39

Anyone can suffer from mental health problems 98 97 94 I would find it hard to talk to someone with mental health problems

10 13 27

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

31 34 52


15 14 19

The majority of people with mental heath problems recover

52 47 42


88 86 80


3 3 7

Source: Ipsos MORI

7.13 The sub-group differences reported above are broadly consistent with findings from the 2004 survey.

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7.14 Hierarchical regression analysis was undertaken to assess the relative strength of different sets of socio-demographic and behavioural variables in terms of their relationship with attitudes towards mental health problems. 7.15 Before carrying out the regression analysis it was necessary to reduce respondents’ answers on the nine different attitude statements to a single dependant variable. A numeric scale was created by allocating values to each of the response categories for each statement. For each positive statement about mental health (i.e. ‘anyone can suffer from mental health problems’, ‘people are generally caring and sympathetic to people with mental health problems’, ‘the majority of people with mental health problems recover’ and ‘people with mental health problems should have the same rights as everyone else’), a value of 1 was allocated for strong disagreement, 2 for a tendency to disagree and so on, up to 5 for strong agreement. For the negative statements (‘if I was suffering from a mental health problem I wouldn’t want anyone knowing about it’, ‘the public should be better protected from people with mental health problems’, people with mental health problems are often dangerous’ and ‘people with mental health problems are largely to blame for their own condition’) a value of 5 was allocated for strong disagreement, 4 for a tendency to disagree and so on down to 1 for strong agreement. These were then summed to give a total value for each respondent. A higher value indicates more positive attitudes towards mental ill-health, and a lower value, more negative attitudes. 7.16 The attitudinal values were put into the regression analysis with the following variables:

- Control over factors affecting mental health - GHQ1219 - Experience of mental ill-health - Key sources of information on mental health problems - Knowledge of National Programme campaigns, initiatives and promotional activity

7.17 Additionally, the following demographic variables were used:

- Age - Sex - Ease of managing on income20 - Education qualifications - Employment status

7.18 The analysis revealed that the regression model explained 10% of the variance in attitudes. Further, no one variable dominated over the others in terms of the strength of its association with attitudes towards mental ill-health. 7.19 However, of the 10 factors included in the analysis, 4 stood out as being more strongly correlated with attitudes than others. The first and strongest of these was mention of personal contact or experience as an important source of information on mental ill-health, that

19 Because a high proportion of respondents were presented with only the first two questions from the GHQ12, these two individual components were included in the analysis in place of GHQ12 score. 20 Income is not listed as the high level of item refusals for this variable meant it was not viable to include it in the analysis.

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is, respondents who mentioned this were less likely to hold negative attitudes towards mental ill-health. 7.20 Consistent with findings reported above, the second strongest factor was age, with older people tending to hold more negative attitudes towards mental ill-health than younger groups. 7.21 The third factor was the GHQ12 item ‘have you recently lost much sleep over worry?’ Those who said they had recently lost sleep rather more than usual or much more than usual also held more negative attitudes. 7.22 The fourth factor also concerned respondents’ main sources of information on mental ill-health, and specifically whether they mentioned health professionals. This was correlated with more positive attitudes towards mental ill-health. 7.23 In sum, the regression analysis identified two main correlates of attitudes towards mental health problems: experience of mental ill-health and sources of information on mental health. Clearly, these two correlates are very much related as the specific sources of information that emerge as significant are personal contact or experience and health professionals. 7.24 It is worth noting at this point that the analysis also found awareness of specific mental health campaigns and initiatives to be correlated with attitudes but the relationship was weaker than for the four factors described above. The relationship between attitudes and awareness of campaigns and initiatives is examined more fully in the next chapter. 7.25 In addition to the regression analysis, segmentation analysis was undertaken on the attitudinal data to explore further the links between attitudes and other variables. However, the resulting data added little value to the findings reported above. A full discussion of the segmentation analysis is provided in Annex I. Perceived prevalence of mental health problems 7.26 To help assess the Executive’s progress towards its target of improving mental health literacy, respondents in the survey were asked how many people in Scotland out of 100 will have a mental health problem at some point in their lives. According to the Mental Health Foundation, the actual lifetime incidence of mental health problems is around 25% (Mental Health Foundation 2003). 7.27 The results are very similar to those obtained in 2004, with respondents tending to over-estimate the prevalence of mental ill-health. Indeed, 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% (table 7.5). 7.28 Again, these findings stand in contrast to results from other similar surveys, in which respondents generally tend to underestimate the prevalence of mental ill-health. For example, in a survey conducted in 2006 by the Health Promotions Agency for Northern Ireland, 63% of respondents underestimated the extent of mental ill-health in their country, with 18% underestimating the figure considerably to be either 1 in 100 or 1 in 1000 (Health Promotion

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Agency, 2006). As was noted in the report on the 2004 Scottish survey, it may be that the higher estimates for Scotland are a function of the various campaigns, initiatives and promotional activity described chapter 1, of which there have been no equivalents in Northern Ireland. However, this may also be a methodological issue and a result of the different way in which the questions was asked in the two surveys. 7.29 As table 7.6 (below) shows, those who had experienced a problem personally, or knew someone close to them who had, gave significantly higher estimates than those with no such experience. Likewise, estimates were higher among those with a high mental ill-health score than among those with a lower score (mean estimates of 52% versus 43%). 7.30 Additionally, women tended to give significantly higher estimates than men. Similarly, people aged 16 to 64 years tended to give higher estimates than people aged 65 and over – although in part this reflects the fact that there was a high proportion of ‘don’t know’ responses among the latter group. Table 7.5: Perceived prevalence of mental ill-health, by subgroups

…Out of 100 people in Scotland how many do you think will have a mental health problem at some stage in their lives?

All

Mal

e

Fem

ale

16-2

4

75+

Pers

onal

ex

peri

ence

Exp

erie

nce

in

som

eone

clo

se

No

expe

rien

ce

Base: (1,216) %

(529) %

(687)%

(108)%

(120) %

(384)%

(870) %

(298) %

1-10 7 12 4 10 15 2 4 16

11-20 6 9 4 6 3 3 5 9

21-30 12 15 10 13 12 8 12 14

31-40 11 13 8 11 6 9 12 9

41-50 18 14 21 11 18 17 17 17

51-60 9 10 8 12 7 9 10 6

61-70 11 8 13 11 1 13 12 8

71-80 13 10 15 15 3 20 15 5

81-90 4 3 5 3 * 8 5 2

91-100 3 3 4 3 2 7 4 1

Don’t know 6 3 9 5 31 4 4 13

Mean 47 43 51 47 26 59 52 33

Source: Ipsos MORI

7.31 Regression analysis was undertaken to explore further the relationship between respondents’ estimates regarding the prevalence of mental health problems and their

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responses to other key questions in the survey. Specifically, the analysis sought to explore the relative influence of the following 5 key factors on respondents’ estimates:

• Willingness to engage with people displaying symptoms of mental ill-health (this measure was derived from a battery of questions which are discussed in detail in the next chapter)

• Someone close to you has experience of mental ill-health

• Someone close to you has experience of any of 15 specific mental health problems (problems as listed in chapter 6)

• Personal experience of mental ill-health

• Personal experience of any of 15 specific mental health problems (problems as listed in chapter 6).

7.32 The analysis revealed that 7 factors were correlated most strongly with estimates regarding the prevalence of mental ill-health and that for all 7, the correlations were positive – that is they were associated with higher estimates. As the chart below shows the strongest factors were being willing to interact with someone displaying symptoms of mental ill-health, and, consistent with findings reported above, having experience of mental ill-health – both personally and with respect to someone close. The other factors were knowing someone who has experienced depression, panic attacks and manic depression, and having personal experience of depression. The figures in the chart indicate the relative strength of each factor. So, for example, experience of mental ill-health in someone close is correlated twice as strongly with estimates of the prevalence of mental ill-health as experience of panic attacks in someone close.

Figure 7.1: Regression analysis of perceived prevalence of mental ill-health

Regression analysis of perceived prevalence of mental ill health

23%

21%

20%

9%

9%

9%

Estimate of prevalence of mental ill health

Willingness to interact with person with symptoms of mental ill health

Personal experience of mental ill health

Experience of mental ill health in someone close

Experience of panic attacks in someone close

Experience of manic depression in someone close

Experience of depression in someone close

Personal experience of depression

10%

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7.33 It is not clear why willingness to interact with a person with mental ill-health should be related to higher prevalence estimates. It may be that people who assume mental ill-health is relatively common are less likely to regard those who suffer from problems as somehow different, abnormal or strange and thus to be avoided. Alternatively, the relationship may be explained by the fact that those willing to interact with a person with symptoms of mental ill-health are more likely to have had a mental health problem themselves or to know someone with a problem - it is clear from the remaining factors that having such experience tends to lead one to assume that mental health problems are more common than they actually are. This may be because those with experience of a problem are more likely to be aware that anyone can suffer from a problem and that sufferers may choose not to disclose their problem for fear of stigma - with the effect that official figures may understate the prevalence of mental ill-health.

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CHAPTER EIGHT: ATTITUDES TOWARDS SPECIFIC SYMPTOMS OF MENTAL ILL-HEALTH 8.1 Chapter 7 considered attitudes towards mental ill-health in general. This chapter explores attitudes towards specific symptoms of mental ill-health, and in particular people exhibiting symptoms associated with three different conditions: depression, schizophrenia and stress. Mental ill-health ‘scenarios’ 8.2 Each respondent in the survey was presented with a scenario depicting a person with symptoms of either depression, schizophrenia or stress. The person in the scenario was either male or female (named Robert or Shona) giving six scenarios in total. The full text of the six scenarios is provided in Annex J. Without being given a diagnosis of the symptoms described, respondents were asked a series of questions about the person in the scenario and his/her symptoms (scenarios were randomly assigned to respondents). The questions focused on the likely cause(s) of the symptoms, possible sources of help, the likelihood of Robert/Shona harming themselves or others, and the extent to which respondents would be willing to interact with them. At the end of the section, respondents were asked to say what condition they thought was being described in the scenario. 8.3 Given that there were six scenarios, each was considered by a relatively small sub sample of respondents. This point should be borne in mind when considering the findings. 8.4 The following section provides an overview of the findings, before focusing specifically on respondents’ willingness to interact with the person depicted in the scenarios under a range of circumstances. A detailed question by question analysis of all findings pertaining to the scenarios can be found in Annex J. Overview of attitudes towards symptoms of depression, schizophrenia and stress 8.5 The most likely causes of the symptoms described in all scenarios were thought to be stressful or disturbing events in Robert’s/Shona’s life and the circumstances in which he/she lives. Those who were shown the depression or schizophrenia scenarios were more likely than other respondents to associate the symptoms with a chemical imbalance in the brain, while those shown the stress scenario were more likely to mention Robert’s/Shona’s own character or personality. 8.6 Respondents who were shown the male versions of the depression or schizophrenia scenarios were more likely than those shown the female version to mention the way he was brought up. Furthermore, those who were shown the male depression scenario were also more likely to feel the symptoms were Robert’s own fault. Meanwhile, those shown the female version of the stress scenario were more likely than those shown the corresponding male version to associate the symptoms with Shona’s upbringing.

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8.7 Between 2004 and 2006, there were significant increases across all scenarios in the proportions of respondents who felt that the symptoms may be associated with Robert’s/Shona’s own character or personality. 8.8 Family doctors, family members and qualified counsellors were seen as the best sources of help for the people in each of the scenarios. However, half of those shown the schizophrenia scenarios mentioned a psychiatrist. Those shown the male versions of the schizophrenia or stress scenarios were more likely to mention family members, while those shown the female version were more likely to mention friends and neighbours. 8.9 Whichever version of the scenario respondents were shown, a majority felt that the best place for Robert/Shona to live was in their own home with support from family members or friends. However, a significant minority of those shown the schizophrenia scenarios thought they should live in special housing with professional support in the community. 8.10 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. 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. 8.11 For all scenarios, majorities said that they would be willing to interact with Robert/Shona under a range of circumstances, including doing them a favour, making friends with them, moving next door to, or spending an evening socialising with them. However, smaller proportions were willing to have Robert/Shona marry into the family and fewer than half in each case said that they would allow them to provide childcare for someone in their family. 8.12 Willingness to interact with Robert/Shona was highest among respondents who were shown the stress scenarios and lowest among those who were shown the schizophrenia scenarios. For each of the scenarios, respondents were generally more willing to interact with a female displaying the symptoms depicted than with a male showing the same symptoms, although whether this is a general feature of people’s willingness to interact with the two sexes, or something specific to people suffering mental health problems, we cannot say. 8.13 Between 2004 and 2006, respondents have become somewhat less willing to interact with the people described in the scenarios. This is particularly evident in terms of: the proportion of those shown the depression scenario who are willing to start working closely with Robert/Shona, or have them marry into the family; the proportion shown the schizophrenia scenario who are willing to make friends with Robert/Shona; and the

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proportion shown the stress scenario who are willing to move next to Robert, to do him a favour or to make friends with Shona. 8.14 Around half of respondents shown the schizophrenia scenario and a third of those shown the depression scenario felt Robert’s/Shona’s freedoms and rights might have to be limited because of their illness. Meanwhile, a lower proportion (around one in five) of those considering the stress scenario felt this was likely. 8.15 While majorities of those shown the depression scenarios were able to attribute the symptoms to the condition correctly, this was not the case for either the schizophrenia or stress scenarios. Indeed, almost half of those considering the stress scenarios thought that Robert/Shona was exhibiting symptoms of depression. Likewise, a significant proportion of those shown the schizophrenia scenario gave diagnoses of depression, a nervous breakdown or a personality disorder. These findings were consistent with those from the 2004 survey. Willingness to interact with the person in the scenarios 8.16 The key measure included in the scenarios section was the item in which respondents were asked how willing they would be to interact with Robert/Shona on a number of different levels, namely:

• Move next door to Robert/Shona • Spend an evening socialising with him/her • Make friends with him/her • Start working closely with him/her • Have him/her marry into the family • Do him/her a favour if he/she asked you to • Have him/her provide childcare for someone in your family (e.g. babysitting,

childminding) 8.17 Table 8.1 presents the aggregate results for the six scenarios. It shows that a majority of respondents would be willing to move next door to Robert/Shona, spend an evening socialising with him/her, make friends with him/her, start working closely with him her and do him/her a favour. However, only two in five would be willing to have Robert/Shona marry into the family and only around half this proportion would be willing to have Robert/Shona provide childcare for someone in their family.

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Table 8.1: Willingness to interact with person in the scenarios – aggregate results for 2006

How willing would you be to…?

Very

will

ing

Fairl

y w

illin

g

Nei

ther

w

illin

g no

r un

will

ing

Fairl

y un

will

ing

Very

un

will

ing

Don

’t kn

ow


Move next door to Robert/Shona

24 42 19 7 4 4

Spend an evening socialising with Robert/Shona

23 46 16 7 4 3

Make friends with Robert/Shona

23 52 15 6 2 3

Start working closely with Robert/Shona

21 41 19 9 4 5

Have Robert/Shona marry into the family

12 29 25 15 12 7

Do Robert/Shona a favour if they asked you

39 50 7 2 1 3

Have Robert/Shona provide childcare for someone in your family

4 16 17 25 32 7

Source: Ipsos MORI

8.18 Analyses were undertaken to explore to what extent responses on the 7 interaction measures varied by a) survey wave b) scenario (both in terms of the gender of the person in the scenarios and his/her symptoms), and c) socio-demographic characteristics of the respondent. The principle statistical technique used for the analyses was ANOVA (analysis of variance) which simultaneously compares the mean responses of a number of sub-groups to identify whether these groups respond identically or otherwise. Variation by survey wave 8.19 The inter-wave analysis aimed to assess the extent to which willingness to interact with the person in the scenario has varied over the 2002, 2004 and 2006 surveys. Table 8.2 shows the mean responses for each of the 7 interaction measures by survey wave. As for all tables present below, the means range from 1 to 5, with 1 indicating a response of ‘very unwilling’, and 5 a response of ‘very willing’.

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Table 8.2: Willingness to interact with person in the scenarios – mean responses How willing would you be to…?

2002 2004 2006

Base: All respondents (1,354) (1,359)

(1,159)

Move next door to Robert/Shona 3.87 3.93 3.77 Spend an evening socialising with Robert/Shona

3.85 3.91 3.79

Make friends with Robert/Shona 3.97 4.08 3.90 Start working closely with Robert/Shona

3.75 3.87 3.67


3.15 3.29 3.09


4.35 4.35 4.26


n/a 2.42 2.28

Aggregate score for all measures 23.04 23.55 22.60

Source: Ipsos MORI

8.20 The analysis revealed that there is no consistent pattern of variation or trend across the three waves of the survey; rather, the picture appears to be one of short term fluctuation. More specifically, between 2002 and 2004, willingness to make friends with Robert/Shona, start working closely with him/her and have him/her marry into the family increased. For the remaining interaction measures, there were no differences between the two waves. Between 2004 and 2006, willingness to interact with Robert/Shona, decreased for all 7 measures, with most of the change significant at the 0.01% level. In general, however, the decreases simply cancelled out the increases observed between 2002 and 2004. In other words, there is little variation between the 2002 and 2006 results - the only exception being in the case of willingness to do Robert/Shona a favour which was lower in 2006 than in 2002. 8.21 The decline in willingness to interact with Robert/Shona between 2004 and 2006 is somewhat surprising given the consistency of attitudes towards mental health between 2004 and 2006 highlighted elsewhere throughout this report. It may be that people today understand more about the symptoms of mental health problems but do not yet feel equipped to cope with them. Alternatively, and as noted in Chapter 7, our exploratory examination of the print media press clippings may point to the potential effects of negative representations of mental ill-health on people’s behavioural intentions. A third possible explanation is methodological and relates to changes in the ordering of questions in the scenarios section for the 2006 survey. In 2004, the ‘willingness to interact’ questions were preceded by a question asking whether the people in the scenarios should have the same rights at work as others. This may have primed respondents to think in terms of equal rights and thus to give more sympathetic responses in the willingness to interact questions. For the 2006 survey the ‘rights’ question was asked after the ‘willingness to interact’ questions, thereby eliminating this potential order effect. The question was moved in 2006 following a decision to change

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the wording of the item 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?” There were concerns that the negative slant of this question may have encouraged respondents to give more negative answers to the ‘willingness to interact’ items, had it preceded those items. Consequently, it may be that in 2006 we are seeing the most ‘honest’ response to these questions. Variation by scenario 8.22 A similar analysis was undertaken to explore the extent to which willingness to interact with someone with mental health problems varied depending on the sex of that person and the nature of his/her symptoms. 8.23 As table 8.3 (below) shows, respondents were consistently more willing to interact with a woman displaying symptoms of mental ill-health, than with a man displaying the same symptoms. This variation was significant at the 0.01% level for each of the 7 interaction measures. These results are consistent with the finding, highlighted elsewhere in this report (Chapter 6), that men who had had a mental health problem were more likely than their female counterparts to have experienced stigma on account of their problem. It may be that men suffering from mental ill-heath are felt to be more unpredictable or to pose more of a threat than women with the same symptoms. Alternatively, the findings may simply be a reflection of people’s willingness to interact with strangers of the two sexes, irrespective of whether or not mental health is an issue. Table 8.3: Willingness to interact with person in the scenarios, by gender of subject – mean responses

How willing would you be to...?

Male subject

Female subject

Base: All respondents Move next door to Robert/Shona 3.79 3.93 Spend an evening socialising with Robert/Shona 3.74 3.96 Make friends with Robert/Shona 3.90 4.06 Start working closely with Robert/Shona 3.66 3.86 Have Robert/Shona marry into the family 3.00 3.34 Do Robert/Shona a favour if they asked you 4.27 4.38 Have Robert/Shona provide childcare for someone in your family

2.19 2.53

Aggregate score for all measures 22.49 23.63

Source: Ipsos MORI 8.24 In terms of the symptoms depicted in the scenarios, willingness to interact with Robert/Shona was highest among those shown the stress scenarios, slightly lower among those shown the depression scenarios and lower still among those shown the schizophrenia scenarios, as table 8.4 (below) illustrates.

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Table 8.4: Willingness to interact with person in the scenarios, by condition depicted – mean responses

How willing would you be to…?

Depression Schizophrenia Stress

Base: All respondents Move next door to Robert/Shona 3.90 3.66 4.03 Spend an evening socialising with Robert/Shona

3.83 3.68 4.06

Make friends with Robert/Shona 3.98 3.68 4.06 Start working closely with Robert/Shona

3.76 3.60 3.94


3.16 2.89 3.50


4.34 4.23 4.40


2.36 2.00 2.76

Aggregate score for all measures 23.03 22.05 24.16

Source: Ipsos MORI

8.25 The analysis also considered whether there was an interaction between the gender of the person in the scenarios and the symptoms depicted for each of the 7 measures – in other words, whether the observed differences in mean response between the male and female versions of the scenarios differed according to symptoms depicted and vice versa. Very little variation was found in this regard, that is, the differences between mean responses for male and female versions of the scenarios were constant, regardless of the symptoms depicted. The only exception was in the case of the “start working closely with Robert/Shona” measure. Here, the gender difference varied for each of the three conditions. Specifically, the difference was most pronounced among those shown the schizophrenia scenarios, slightly smaller among those shown the depression scenario and marginal among those shown the stress scenario. In other words respondents were: much more willing to work with a female showing symptoms of schizophrenia than with a male showing the sample symptoms; somewhat more willing to work with a female with depression than with a male with depression21; and almost equally as willing to work with a female with stress as with a male with stress (see figure 8.1 below). 8.26 Reasons for these differences are unclear. One possible explanation is that, of all the measures of interaction listed, working closely with Robert/Shona involves the closest and most sustained level of contact with him/her. Further, any potential difficulties arising as a consequence of Robert’s/Shona’s symptoms could be seen to pose more of a problem a work

21 Wolpert (2001) mentions the reluctance of people to work alongside those who have depression because depressed individuals are seen to have a negative impact on those with whom they interact.

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setting than in less formal social setting. These considerations, combined with the hypothesis, set out above, that people are more wary of males with mental health problems than with females with the same problems, may account for the more cautious responses to the male versions of the schizophrenia and depression scenarios Figure 8.1: Willingness to start working closely with Robert/Shona - interaction between gender and symptoms of person in scenario

3.20

3.30

3.40

3.50

3.60

3.70

3.80

3.90

4.00

Female Male

Sex

Mea

n Sc

ore

Depression Schizophrenia Stress.

Variation by socio-demographic characteristics of the respondent 8.27 This analysis considered to what extent willingness to interact with the person in the scenarios varied according to respondents’ gender, age and income. 8.28 Gender was found to be an important discriminator on two of the interaction measures, namely, willingness to spend an evening socialising with Robert/Shona and willingness to make friends with him/her. In both cases, the mean response among women was higher than that among men (table 8.5). These results are consistent with the finding, reported in Chapter 7, that women were less likely than men to say that they would find it hard to talk to someone with a mental health problem.

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Table 8.5: Willingness to interact with person in the scenarios, by gender of respondents – mean responses

How willing would you be to...?

Men Women

Base: All respondents Move next door to Robert/Shona 3.810 3.915 Spend an evening socialising with Robert/Shona 3.791 4.027 Make friends with Robert/Shona 3.941 4.137 Start working closely with Robert/Shona 3.713 3.881 Have Robert/Shona marry into the family 3.129 3.356 Do Robert/Shona a favour if they asked you 4.294 4.404 Have Robert/Shona provide childcare for someone in your family

2.412 2.371

Aggregate score for all measures 22.743 23.762

Source: Ipsos MORI 8.29 For willingness to make friends with Robert/Shona there was also an interaction between gender and income, that is, the observed differences in mean response between male and female respondents on this measure varied according to their income. Among males, willingness to make friends with Robert/Shona decreased as income rose, in other words, men on a lower income expressed a higher level of willingness than those on a higher income. Among women a somewhat different pattern emerged: the lowest and highest income groups were more willing to make friends with Robert/Shona than those on middle-level incomes (see figure 8.2).

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Figure 8.2: Willingness to make friends with person in the scenarios –interaction between gender and income of respondents

3.50

3.60

3.70

3.80

3.90

4.00

4.10

4.20

4.30

4.40

Less than£5,200

Betw een£5,200 and

£15,600

Betw een£15,600 and

£26,000

Betw een£26,000 and

£36,400

£36,400 or more

Income Band

Will

ingn

ess

to m

ake

frie

nds

with

Rob

ert/S

hona

- m

ean

scor

e

Female

Male

8.30 Respondents’ age was found to be an important discriminator for two of the interaction measures - willingness to have Robert/Shona marry into the family and to provide childcare. Younger respondents, i.e. those aged up to 44 years, were more likely than those aged 45 and over to say they would be willing to have Robert/Shona marry into their family (table 8.6). Similarly, people aged 25 to 35 years expressed a higher level of willingness than those aged 75 and over to have Robert/Shona provide childcare. These findings are consistent with the age-based variation in attitudes towards people with mental health problems, reported in chapter 7, and specifically the finding that people aged 75 and over were among those most likely to agree that the public should be better protected from people with mental health problems and people with mental health problems are often dangerous.

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Table 8.6: Willingness to interact with person in the scenarios, by age – mean responses How willing would you be to…?

16-24 25-34 35-44 45-54 55-59 60-64 65-74 75+

Base: All respondents Move next door to Robert/Shona

4.006 3.859 3.964 3.920 3.878 3.715 3.714 3.830


4.054 3.891 3.986 3.965 3.900 3.855 3.991 3.585


4.123 3.943 4.070 4.103 4.001 3.973 4.138 3.968


3.981 3.787 3.919 3.956 3.818 3.706 3.783 3.344


3.671 3.472 3.534 3.426 3.210 2.965 2.844 2.678


4.351 4.301 4.390 4.422 4.328 4.307 4.439 4.247


2.711 2.588 2.542 2.564 2.327 2.217 2.220 1.832

Aggregate score for all measures

24.209 23.290 24.001 23.833 23.346 22.558 22.699 21.786

Source: MORI

8.31 There was no other variation by respondents’ socio-demographic characteristics.

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CHAPTER NINE: SOURCES OF INFORMATION ON MENTAL HEALTH PROBLEMS AND AWARENESS OF CAMPAIGNS, INITIATIVES AND PROMOTIONAL ACTIVITY 9.1 This chapter begins by considering how respondents have formed their impressions of mental health problems. It then explores their general recall of adverts and promotions about mental health and mental health problems, as well as their awareness of specific campaigns, initiatives and promotional activity. Forming impressions and opinions about mental health problems 9.2 Asked which sources of information had been most important in forming their impressions about mental health problems, respondents most commonly mentioned personal contact or experience (59%) and television news and current affairs (45%). That said, newspapers, work, word of mouth and health professionals were also mentioned by relatively large numbers of people. These results are very much consistent with the comparable findings for 2004, although there has been a significant decrease in the proportion mentioning word of mouth (table 9.1). 9.3 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%. The latter highlights the significant influence of televisual media representations on the formation of attitudes and beliefs. Work becomes the third most important source, (10%) ahead of national newspapers (4%). No other single source was mentioned by more than one in ten respondents (table 9.1).

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Table 9.1: Forming impressions and opinions about mental health problems Q1. I’m interested to know how you have gained your understanding of mental health problems and how they affect people’s lives. Taking your answers from this card, which, if any, of the following have been important in forming your impression?

Q2. Which one of these sources would you say was the most influential for you?

Q1 Q2

2002 2004 2006 2002 2004 2006

Base: (1,381) %

(1,401)%

(1,216)%

(1,381)%

(1,401)%

(1,216) %

Personal contact or personal experience

38 57 59 21 39 41

Television news and current affairs

51 44 45 18 15 16

National newspapers 34 26 29 8 4 4 Work 20 24 26 7 8 10 Word of mouth 29 32 25 5 7 5 Health professionals 33 27 25 17 8 7 Books/leaflets/magazines 28 24 21 5 3 3 Television soaps 14 15 16 2 2 3 School/college 17 13 10 3 4 3 Local newspapers 16 13 10 2 1 1 Radio 10 10 9 1 1 1 Other TV 6 12 9 1 2 1 Internet 1 5 8 * * 1 Other 1 1 3 1 * 1 None of these 6 3 2 6 4 3 Don’t know 1 1 2 2 2 3

Source: Ipsos MORI

9.4 Notwithstanding this general picture, there was some notable sub-group variation in the data. Men, especially those aged 35 to 54 years, were among those most likely to mention television news and national newspapers as one of their main sources, whereas books, leaflets, magazines, and television soaps were predominantly mentioned by women. Additionally, people aged 25 to 44 years, were among those most likely to mention personal contact or experience (table 9.2). This is consistent with the finding, reported in chapter 6, that younger people were more likely than older groups to have proxy experience of mental ill-health. 9.5 There was further variation by economic indicators with the highest earners being significantly more likely than lower income groups to mention media sources, work, health professionals, books, leaflets and magazines.

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Table 9.2: Forming impressions and opinions about mental health problems, by sub-groups Q1. I’m interested to know how you have gained your understanding of mental health problems and how they affect people’s lives. Taking your answers from this card, which, if any, of the following have been important in forming your impression?

Pers

onal

co

ntac

t/Exp

erie

nce

Tel

evis

ion

new

s

Nat

iona

l ne

wsp

aper

s

Wor

k

Hea

lth

prof

essi

onal

s

Boo

ks/le

afle

ts

mag

azin

es

Tel

evis

ion

soap

s

Row percentages % % % % % % %

Men (529) 57 48 33 23 23 18 12

Women (687) 62 42 26 29 27 24 19

16-24 (108) 49 42 24 15 17 24 22

25-34 (164) 70 49 27 28 25 19 10

35-44 (225) 67 52 35 35 34 32 22

45-54 (196) 57 46 33 30 30 20 15

55-59 (110) 58 43 23 28 28 16 15

60-64 (116) 58 37 30 32 28 23 16

65-74 (177) 57 42 36 24 17 16 10

75+ (120) 49 39 19 10 10 8 12

Men 16-34 (128) 61 49 32 15 18 16 15

Men 35-54 (179) 57 54 38 31 31 24 13

Men 55+ (222) 52 41 30 24 20 13 10

Women 16-34 (144) 59 42 18 29 25 26 18

Women 35-54 (242) 67 45 31 35 33 29 24

Women 55+ (301) 58 40 26 24 22 19 16

Annual household income less than £5,200 (71)

49 35 27 15 26 18 16

Annual household income £36,000 or more (114)

64 58 46 48 44 41 18

Source: Ipsos MORI

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General recall of adverts or promotions about mental health/mental health problems 9.6 Among the aims of the National Programme for Improving Mental Health and Wellbeing are improving awareness of mental health and promoting positive shifts in attitudes towards mental health problems. A number of major campaigns, initiatives and promotional activities have been launched to help achieve these aims, including the ongoing ‘see me …’ anti-stigma and discrimination campaign, which has included advertisements in various media. The present survey included a set of questions to gauge awareness of this type of activity. 9.7 Four in every five (79%) respondents 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%). This is perhaps unsurprising as the last two years have seen a significant increase in the number of mental health campaigns, initiatives and promotional activity taking place in Scotland (see below). 9.8 Over half of respondents said they 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. Twelve percent mentioned each of magazine adverts, billboards/bus adverts and radio adverts, and just 4% mentioned adverts or promotions on the internet. While these figures are broadly in line with those for 2004, the proportions mentioning television/cinema adverts and newspaper adverts have both increased significantly, by 9 and 5 percentage points respectively. 9.9 As table 9.3 (below) shows, people aged 25 to 59 years were generally more likely to recall any type of advert or promotion than the younger or older age groups, and those in less deprived areas were more likely to do so than those in the most deprived areas. Recall was also higher among people with some experience of mental ill-health - whether personally or in someone close to them - than among those with no such experience. Reflecting this, respondents with a high mental ill-health score were more likely than those with a low score to say they had seen, read or heard an advert or promotion in a doctor’s or other type of surgery or on television/at the cinema. 9.10 There were few regional differences but people living in the North East were significantly more likely than those in all other areas to recall seeing an advert or promotion on television or at the cinema. Reasons for this difference are unclear but it may be a legacy of work undertaken by Grampian Health Board in 2002 to boost the national ‘see me…’ campaign in their own area.

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Table 9.3 Recall of adverts or promotions about mental health Q In the last year, have you seen, read or heard an advert or promotion about mental health/mental health problems in any of these places?

Yes

(any

)

Adv

ert i

n ne

wsp

aper

Adv

ert i

n m

agaz

ine

Lea

flet i

n D

r/ot

her

Surg

ery

Adv

ert o

n bi

llboa

rd/b

us

Adv

ert o

n T

V/a

t ci

nem

a

Adv

ert o

n ra

dio

% % % % % % %

All (1,216) 79 20 12 30 12 55 12

Men (529) 79 22 10 27 13 56 13

Women (687) 80 19 13 34 11 54 10

16-24 (108) 86 14 15 34 21 56 12

25-34 (164) 84 19 9 31 22 60 13

35-44 (225) 85 22 14 37 9 63 17

45-54 (196) 83 24 13 26 12 58 15

55-59 (110) 85 24 13 35 11 62 11

60-64 (116) 79 25 14 39 3 52 11

65-74 (177) 70 18 7 21 6 44 6

75+ (120) 51 15 5 14 - 29 1

Borders and South (137)

77 23 15 32 13 47 12

Central Belt West (367)

78 20 10 31 14 55 14

Highlands and Islands (210)

78 21 10 29 7 53 8

Lothian and Fife (268) 81 20 12 30 13 52 14

North East (234) 83 19 13 30 11 65 8

Personal experience of mental health problems (384)

85 19 14 37 13 61 17

No personal experience of mental health problems (298)

63 12 9 14 6 42 4

Low mental ill-health score (379)

80 17 9 29 11 49 10

High mental ill-health score (81)

87 19 13 44 12 73 10

Source: Ipsos MORI

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Awareness of key campaigns, initiatives and promotional activity 9.11 In the 2004 survey, respondents were presented with a list of five specific mental health campaigns, initiatives and 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 and discrimination campaign • the ‘Breathing Space’ telephone advice line for people experiencing low mood or

depression • Mental Health First Aid training • the Scottish Recovery Network

9.12 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 9.13 These various campaigns and initiatives associated with the National Programme differ greatly in message, media used, style of delivery, target group and level of funding. This is likely to have a significant bearing on public awareness of each. For example, we would anticipate that people would be more aware of ‘see me…’ than other initiatives because it is specifically a media campaign. 9.14 The results confirm this hypothesis. 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. 9.15 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%). 9.16 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. 9.17 Awareness of the various campaigns, initiatives and promotional activity varied among different sub-groups. Consistent with their higher reliance on leaflets and magazines in forming an impression of mental health problems, women were almost twice as likely as

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men to be aware of ‘Well’ magazine (31% versus 18% respectively). In part, this may be because they are more likely than men to visit doctors’ surgeries and the other types of places where the magazine is available. 9.18 Awareness of ‘Choose Life’, ‘see me…’, ‘Breathing Space’, and ‘HeadsUpScotland’ decreased with age, but awareness of ASIST was at it highest among people aged 35 to 54 years (table 9.4 below). Table 9.4: Awareness of mental health campaigns, initiatives and promotional activity, by age

Q. There have been a number of campaigns, initiatives and promotional activity regarding mental health in Scotland. Have you heard of any of the following or not?

% Yes Male Female All 16-34 35-54 55+ 16-34 35-54 55+

Base: (1,216) %

(128) %

(179) %

(222) %

(144) %

(242) %

(301) %

‘Choose Life’, the national strategy and action plan to prevent suicide

32 42 38 18 38 44 17

‘see me…’ The national anti-stigma campaign

37 52 40 15 52 48 20

The ‘Breathing Space’ telephone advice line

24 35 26 10 39 28 10

Mental Health First Aid 10 10 11 9 11 12 9

The Scottish Recovery Network

10 10 10 8 9 14 5

ASIST suicide prevention training

16 16 19 12 15 21 10

‘ArtFull’ 9 12 11 10 4 9 8

‘HeadsUpScotland’ 19 27 20 17 26 20 10

‘Doing Well by People’ with Depression

8 8 7 5 9 13 8

‘Well’ magazine 25 18 19 18 31 38 26

Source: Ipsos MORI

9.19 As in 2004, awareness of the campaigns, initiatives and promotional activity also varied by NHS Board area. In particular:

• Awareness of ‘see me…’ was significantly higher in the North East than in the Borders and South (43% versus 30% respectively)

• Awareness of ‘Breathing Space’ was higher in Central Belt West and the North East than in the Borders (29% and 26% versus 15% respectively)

• Awareness of ‘Artfull’ was higher in the Borders and South than in all other areas (16% versus 7% in Central Belt West, the Highlands and Islands and Lothian and Fife, and 11% in the North East)

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9.20 Again, the higher awareness of ‘see me…’ in the North East is likely to reflect the additional work undertaken by Grampian NHS in their area. The differential awareness of ‘Breathing Space’ and ‘Artfull’ is more puzzling. ‘Breathing Space’, although initially promoted in Greater Glasgow, Argyll and Clyde, was rolled out nationally by the end of 2004. ‘Artfull’, similarly is a national initiative and certainly the number of related organisations and projects in the Borders and South is no higher than in other NHS Board areas. 9.21 With the exception of ‘Artfull’, ‘HeadsUpScotland’ and ‘Doing Well’, the campaigns, initiatives and promotional activity generally had a higher profile among people who have had a mental health problem or witnessed a problem in someone close to them, than among those with no such experience, (table 9.5 below). More specifically, those with personal or proxy experience of mental ill-health were twice as likely to have heard of ‘see me…’, ‘Breathing Space’, the Scottish Recovery Network and ASIST. Similarly, ‘Choose Life’ was familiar to around a quarter of those with no experience of mental ill-health, compared to over a third of those with personal or proxy experience. On one level, these findings are intuitive - it might be expected that people for whom mental ill-health is an issue will be more likely to notice relevant campaigns and initiatives. However, the results also provide an indication that the campaigns and initiatives are reaching those to whom they are likely to be most helpful.

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Table 9.5: Awareness of mental health campaigns, initiatives and promotional activity, by personal experience of mental ill-health

Q. There have been a number of campaigns, initiatives and promotional activity regarding mental health in Scotland. Have you heard of any of the following or not?

% who have heard of each campaign

People with personal

experience of mental ill-

health

People with proxy experience of mental ill-health

People with no

experience of mental ill-health

Base:

Row percentages

(384) %

(870) %

(298) %

‘Choose Life’ 34 36 23 ‘see me…’ 43 42 21 ‘Breathing Space’ 29 28 12 Mental Health First Aid 9 12 7 The Scottish Recovery Network 13 11 5 ASIST 16 19 8 ‘ArtFull’ 11 9 8 ‘HeadsUpScotland’ 19 22 14 ‘Doing Well by People with Depression’

9 9 7

‘Well’ magazine 27 28 19

Source: Ipsos MORI

9.22 Correlation analysis was undertaken to explore further the relationship between awareness of the campaigns, initiatives and promotional activity, and experience of mental ill-health. To provide as full as possible an exploration of the data, five different measures of awareness were considered namely:

• Awareness of any campaign, initiative or promotional activity • The total number of campaigns, initiatives and promotional activities of which

respondents had heard • Awareness of either of the suicide prevention initiatives, ‘Choose Life’ or ASIST • Awareness of ‘HeadsUpScotland’, the national project for children’s and young

people’s mental health • Awareness of either of the training intervention initiatives, ASIST or Mental Health

First Aid.

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9.23 The analysis revealed that all five of these measures of awareness were correlated with proxy22 experience of mental ill-health, but only the first measure – awareness of any campaign or initiative - was correlated with personal experience of mental ill-health. Further, all five measures were correlated with proxy experience of depression and panic attacks specifically. 9.24 Additionally, the second measure of awareness - the number of campaigns of which respondents had heard - was correlated with proxy experience of eating disorders, manic depression, self harm, postnatal depression and severe stress, while awareness of the suicide prevention initiatives was correlated with proxy experience of postnatal depression and self harm. Awareness of ‘HeadsUpScotland’ was correlated with proxy experience of self harm only. 9.25 The results of the correlation analysis are largely intuitive but are important as they are reinforced by research evidence. As already noted, we would expect those with experience of mental health problems to be both more exposed to, and more likely to take notice of, mental health campaigns and initiatives than those with no experience. For similar reasons, we might also expect the observed associations between awareness of specific campaigns and initiatives and experience of particular conditions. For example, in relation to the association between ‘HeadsUpScotland’ and proxy experience of self harm, this initiative is aimed at supporting young people and as self harm is relatively common in young people (e.g., approximately 1 in 10 adolescents self harm, Hawton & Rodham, 2006), this finding is unsurprising. 9.26 As already noted, some of the campaigns, initiatives and promotional activity are aimed at promoting positive shifts in attitudes to mental ill-health. Accordingly, correlation analysis was also undertaken to explore the links between awareness of the campaigns, initiatives and promotional activity and attitudes towards mental health (as measured in the previous chapter), including willingness to interact with someone with a mental health problem. Again, the analysis considered the 5 different measures of awareness, set out above. 9.27 Table 9.6 (below) summarises the results of the analysis. It highlights all correlations identified and whether these were positive or negative in direction. 9.28 All five measures of awareness were correlated positively with willingness to interact with someone with a mental health problem, working closely with them. In other words, on each of the measures, those with the highest levels of awareness of the campaigns and/or initiatives were more willing to interact with someone with a mental health problem under a range of circumstances - these include, making friends with them, moving next door to them and working closely with them. 9.29 Three of the measures of awareness – awareness of any campaign, initiative or promotional activity; total numbers of campaigns aware of; and awareness of suicide prevention initiatives – were also correlated with positive attitudes towards mental ill-health. Thus, those with higher awareness on these measures were more likely to inter alia 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 with the statement that the public should be better protected from people with mental health problems and that people with

22 i.e. knowing someone who has experienced a mental health problem

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mental health problems are often dangerous. However, none of the 3 measures of awareness was correlated with response to the statement, ‘If I were suffering from mental health problems I wouldn’t want people knowing about it’. In other words, whether people agreed or disagreed with the statement had no relationship with their awareness of campaign or promotional activity. This suggests that the processes which are associated with changing attitudes towards those with mental health problems are different from those associated with changing your beliefs when the mental health problems concern yourself - perhaps this could be characterised as someone who is not prejudiced themselves but recognises that prejudice exists and consequently is reluctant to disclose. Further, all of the measures of awareness were negatively correlated with the view that people are generally caring and sympathetic towards people with mental health problems - in other words, the more campaigns and initiatives people had heard of the less likely they were to agree with this statement. The latter finding may be a reflection of the fact that the ‘see me…’ campaign in particular has tended to highlight the stigma surrounding mental health, albeit with a view to challenging this, which in turn may have contributed to a view of the general public as uncaring towards those with problems. 9.30 With regard to the remaining measures of awareness, familiarity with the intervention initiatives was correlated with the view that people with mental health problems should have the same rights as anyone else, but, as in the preceding analysis, negatively correlated with the view that people are generally caring and sympathetic towards people with mental health problems. Meanwhile, ‘HeadsUpScotland’ was correlated with just one of the attitudinal statements, namely, ‘the public should be better protected from people with mental health problems’ – those who had heard of ‘HeadsUpScotland’ were less likely to agree with this. 9.31 While correlation analysis cannot tell us anything about the causal direction of the relationship between two sets of findings, the results do provide cause for optimism. Awareness of campaigns and initiatives does appear to be correlated with more positive attitudes towards mental ill-health, including willingness to interact with people with mental health problems. That said, the absence of a correlation between awareness of campaigns and initiatives, and response to the statement, ‘If I was suffering from a mental health problem I wouldn’t want people knowing about it’ suggests that stigma is fairly complex in nature, and that while campaigns and initiatives may be helping to change attitudes, there may still be some way to go before this is reflected in changing behaviour.

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Table 9.6: Correlation analysis of awareness of campaigns, initiatives and promotional activity, and attitudes to mental ill-health

Measure of awareness of campaigns/initiatives

Aw

are

of a

ny

Tot

al n

umbe

r aw

are

of

Aw

are

of su

icid

e in

itiat

ive

Aw

are

of

Hea

dsU

pSco

tland

Aw

are

of

inte

rven

tion

initi

ativ

e s

Base: All respondents



_

_ _

_


+

+

+


_

_ _


_

_ _

_


_

_ _



+

+

+

+


_

_

Willingness to interact with someone with a mental health problem

+

+

+

+

+

Source: Ipsos MORI

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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

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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

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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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REFERENCES Brown, W. and Kandirikirira, N., Narrative Research Report. http://www.scottishrecovery.net/content/default.asp?page=s5_4 Cattan, M., White, M., Bond, J., & Learmouth, A. (2005), ‘Preventing social isolation and loneliness among older people: a systematic review of health promotion interventions’, Ageing and Society, 25, 41-67 DeMoranville, C.W. & Bienstock, C.C. (2003), ‘Question order effects in measuring service quality’, International Journal of Research in Marketing, 20, 217-231 European Commission (2005), Green Paper – ‘Improving the mental health of the population: Towards a strategy on mental health for the European Union’ Galdas, P.M., Cheater, F. & Marshall, P. (2005), ‘Men and health help-seeking behaviour. A literature review’, Journal of Advanced Nursing, 49, 616-623 Goldberg, D. & Williams P. (1991), A User’s Guide to the General Health Questionnaire, Hampshire: nferNelson Publishing Company Ltd Hawton, K. & Rodham, K. (2006), By their own hand: deliberate self-harm and suicidal ideas in adolescents, London: Jessica Kingsley Publishers Health Promotion Agency (2006), Public attitudes, perceptions and understanding of mental health in Ireland, Belfast: Health Promotion Agency Jane-Llopis, E. & Anderson, P. (Eds) (2006), Mental health promotion and mental disorder prevention across European member states: a collection of country stories, Luxembourg: European Communities Link, B., Phelan, J., Bresnahan, M., Stueve, A. and Pescosolido, B (1999) ‘Public Conceptions of Mental Illness’: Labels, Causes, Dangerousness and Social Distance, American Journal of Public Health, Vol.89, No.8, pp.1328-1332 Mangalore, R., Knapp, M. & Jenkins, R. (2007), ‘Income-related inequality in mental health in Britain: the concentration index approach’,http://journals.cambridge.org/action/display Abstract;jsessionid=77B23A81473C1F6FDA132F46BD1E3ACD.tomcat1?fromPage=online&aid=636804#c1 Meltzer, H., Lader, D., Corbin, T., et al. (2002), Non-fatal suicidal behaviour among adults aged 16 to 74 in Great Britain, London: The Stationery Office Mental Health Foundation (1993), Mental Illness: The Fundamental Facts, Mental Health Foundation, London Mental Health Ireland (2005), Public Attitudes to Mental Health: http://www.mentalhealthireland.ie/news/Key%20Findings%20Report%202005.doc

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Miller, M. (1979), Suicide after sixty: the final alternative, New York: Springer Muijen, M. (2006), ‘Challenges for psychiatry: delivering the Mental Health Declaration for Europe’, World Psychiatry, 5, 113-117 Munoz-Arroyo, R., Sutton, & Morrison, J. (2006), ‘Exploring potential explanations for the increase in antidepressant prescribing in Scotland using secondary analyses of routine data’, British Journal of General Practice, 56, 423–428 NHS Scotland (2003), Partnership for Care: Scotland’s Health White Paper, Edinburgh: The Stationery Office O’Conner et al, (2007), ‘Predicting Short-term Outcome in Wellbeing Following Suicidal Behaviour: The Conjoint Effects of Social Perfectionism and Positive Future Thinking’, Behaviour Research and Therapy, in press Parkinson, J. (2006) ‘Measuring Positve Mental Health: Developing a New Scale’ http://www.healthscotland.com/uploads/documents/3046- measuring%20mental%20well-being%20%Affectometer%202%20- %20WEMWBS%20briefing.pdf Platt, S., Boyle, P., Crombie, I., Feng, Z. & Exter, D. (2007) The Epidemiology of Suicide in Scotland 1989-2004: An Examination of Temporal Trends and Risk Factors at National and Local Level, Edinburgh: The Scottish Executive Putnam, R. (2000), Bowling Alone: The Collapse and Revival of American Community, New York: Simon & Schuster Ltd. SAMH (2006) What’s It Worth? The Social and Economic Costs of Mental Health Problems in Scotland, Glasgow: SAMH Scottish Executive (2006), Delivering for Mental Health, Edinburgh: The Scottish Executive Scottish Executive (2005), Delivering for Health, Edinburgh: The Scottish Executive Scottish Executive (2005), The Scottish Health Survey – 2003 results, Edinburgh: The Scottish Executive Scottish Executive (2003), Improving Health in Scotland: The Challenge, Edinburgh: The Stationery Office SEU (2004), Social Exclusion and Mental Health, London: Office of the Deputy Prime Minister Singleton, N., Bumpstead, R., O’Brian M., Lee, A. & Meltzer, H. (2000), Psychiatric morbidity among adults living in private households, 2000, London: The Stationery Office Stansfeld, A. & Marmot, M.J. (Eds) (2001), Stress and the heart: psycho-social pathways to coronary heat disease, BMJ Books

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Tennant, R., Fishwick, R., Platt, S., Joseph, F. & Stewart-Brown S., Monitoring Positive Mental Health in Scotland: validating the Affectometer 2 scale and developing the Warwick-Edinburgh Mental Wellbeing Scale for the UK (Draft paper) Ueno, K. (2005), ‘The effects of friendship networks on adolescent depressive symptoms’, Social Science Research, 34, 484-510 Vauth, R., Kleim, B., Wirtz, M. & Corrigan, P.W. (2007), Self-efficacy and empowerment as outcomes of self-stigmatising and coping in schizophrenia, Psychiatry Research, 150, 71-80 WHO (2003), Investing in Mental Health, Geneva: WHO WHO Regional Office for Europe (2005), Mental health: facing the challenges, building solutions, Report of the WHO European Ministerial Conference, 2005. Copenhagen: WHO Regional Office for Europe Wolpert, L. (2001), Malignant Sadness: The Anatomy of Depression, London: Faber and Faber

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ANNEX A: ADVANCE LETTER

The Householder

Ipsos MORI Scotland 4 Wemyss Place

Edinburgh EH3 6DH

Email: [email protected]

Phone: 0800 328 9834

Dear Householder, Important Survey in Scotland I am writing to ask for your help with an important survey we are conducting across Scotland on behalf of the Scottish Executive. Your household has been picked at random from the Post Office list of addresses to take part in the survey. The survey is called ‘Well? What do you think?’ It covers topics such as what you think about your health, wellbeing and quality of life issues. An interviewer will be visiting you soon. They will show you their official identification card, which includes a photograph and will select an adult in your household at random to take part in this survey. The questions will take around 30 minutes to complete. If you are busy when they call, they will be happy to call back at another time. Participation in the survey is voluntary, but we rely on people’s help to make sure that the results represent the experiences of everyone in Scotland, so we hope you will agree to take part. If there are any questions you do not want to answer, you can refuse them and, of course, you will be free to stop the interview at any time. Your answers will be treated in the strictest confidence. They will be used only for research and statistical purposes and you will not be personally identifiable. No-one will try to sell you anything and you will not receive any ‘junk mail’ as a result. In order to ensure that the survey covers a wide range of experiences, Ipsos MORI will try to ensure that any particular needs you have (relating to language, sensory abilities etc) are accommodated in the interview. We would be happy to discuss this with you further if necessary. So, when we come to your door, we hope you’ll help us. If you would like to speak to someone about the survey please call freephone 0800 328 9834, write to Katherine Myant at the above address, or email [email protected] Thank you in advance for your help. Yours faithfully,

Simon Braunholtz Managing Director, Ipsos MORI Scotland

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ANNEX B: SURVEY ADMINISTRATION B.1 An advance letter was sent to all sampled households from the Scottish Executive. The letter was printed on headed paper and signed by the Managing Director of Ipsos MORI. Because the Postal Address File does not identify the names of householders, the letters were addressed to ‘Dear Householder’. The advance letter was designed to provide basic information about the survey, but to avoid giving prominence to the issue of mental health. The copy of the advance letter can be found in Annex A. B.2 A contact sheet was designed and printed for each address in the sample, 2,372 in total. The contact sheets acted as a record of each visit for each selected address. It was fully data entered to record information on the number of calls made to achieve an interview, as well as the day and time of each interview. In addition it recorded important information on the outcome of the interview, i.e. successful interview, refusal information, no contact or other as tables C.1, C.2 and C.3 show. B.3 All fieldwork on this project was conducted by Ipsos MORI’s fully trained fieldforce. All interviewing on this project was conducted using CAPI (Computer Assisted Personal Interviewing). Interviewers were instructed to download their successful interviews at the end of each day so that the project team could monitor progress throughout fieldwork. Interviewers were also instructed to return all contact sheets (successful and otherwise) to the Ipsos MORI field department in London so that the data could be entered to monitor progress.

112

Table B.1: Summary table and record of achievals Summary No. % of total

valid sample

Issued sample 2,372

Out of scope addresses 221

Remaining valid sample 2,151

Successful interviews 1,216 57

Refused 438 20

No contacts/other 557 25

Achievals after number of calls % of total achievals

Interviews achieved after 1 call 401 33

Interviews achieved after 2 calls 338 28




Interviews achieved after 6+ calls 53 4

Total achievals 1,216

Table B.2: Final Outcomes

Final Outcomes – No contacts/other

No. % of total valid sample

No contacts 391 18

Too ill 36 2

Away during fieldwork 19 1

Mother tongue required 8 *

Other 58 3

Withdrawn by Head Office 45 2

Total no contacts/property ineligible/other 557 26

Source: Ipsos MORI

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Table B.3: Refusal information Refusal information No. % of total

valid sample

Number addresses refused 438 18

% of total refused

addresses

Refused before respondent selection 317 72

Refused after respondent selection 120 27

Entry to block/scheme refused by warden 1 *

Never does surveys 72 16

Interview takes too long 11 3

Taken part in too many surveys 12 3

Too busy at this time 88 20

Always too busy 44 10

Worried about misuse of information/confidentiality

17 4

Worried about safety/security 1 *

Survey is a waste of money 2 *

Not interested in helping government 16 4

Not interested in the subject matter/ don’t want to talk about mental health

60 14

‘Nothing in it for me’ 4 1

Other 62 14

Total number of refusal codes 389

Source: Ipsos MORI

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ANNEX C: CONTACT SHEET

©MORI - PROPERTY OF MARKET & OPINION RESEARCH INTERNATIONAL

Ipsos MORI/J28801

SCOTTISH EXECUTIVEPublic Attitudes Survey

CONTACT SHEET «Barcode»

Address Number: «Uniqid»

Issue Interviewer Name: Number: 1

2 AD

DR

ESS

INFO

RM

ATI

ON

AMEND ADDRESS IF NECESSARY THE HOUSEHOLDER «add01» «add02» «add03» «add04» «add05» «add06» «pcode»

3

WEEKDAY (1-7)

TIME (1-3)

DAY (1-31)

MONTH (1-12) COMMENTS - record outcome of each call

1

2

3

4

5

6

TOTAL NUMBER OF CALLS (WRITE IN BOX)

YOU MUST RECORD AT LEAST 4 ATTEMPTS IN TOTAL TO MAKE APPOINTMENT/COMPLETE INTERVIEW BEFORE ABANDONING ADDRESS.

AT LEAST ONE CALL MUST BE AN EVENING AND ONE AT A WEEKEND . DAY MON = 1 TUES = 2 WED = 3 THURS = 4 FRI = 5 SAT = 6 SUN = 7

CO

NTA

CT

REC

OR

D

CONTACT CODES: TIME UP TO MIDDAY = 1 MIDDAY - 6PM = 2 6PM ONWARDS = 3

FINAL OUTCOME Reissue

Successful interview 1 1 Refused before respondent selection 2 2

Refused after respondent selection 3 3

REF

USE

D

Entry to block/scheme refused by warden etc com

plet

e re

fusa

l inf

o

4 4

Occupied, no contact at address after 4+ calls 5 5 No contact with selected resident, 4+ calls 6 6

Occupier in but not answering door after 4+ calls 7 7 NO

C

ON

TAC

T

Unsure if occupied, no contact after 4+ calls 8 8 Property vacant 9 9

Property demolished/derelict 10 10 Property not yet built 11 11

Non-residential property 12 12 Institution – no private household 13 13 PR

OPE

RTY

IN

ELIG

IBLE

Not found – no trace of address 14 14 Too ill to participate WRITE IN DESCRIPTION 15 15

Away during fieldwork WRITE IN DATE BACK 16 16

Mother tongue required WRITE IN LANGUAGE 17 17

Other WRITE

IN 18 18

OTH

ER

Withdrawn by Head Office 19 19

REFUSAL INFORMATION Reissue

Never does surveys 1 1 Interview takes too long 2 2

Taken part in too many surveys 3 3 Interview is too intrusive 4 4

Too busy at this time 5 5 Always too busy 6 6

Worried about misuse of information 7 7

Worried about confidentiality 8 8 Worried about safety/security 9 9

Survey is a waste of money 10 10 Not interested in helping

government 11 11

Not interested in the subject matter 12 12

“Nothing in it for me” 13 13 Don’t want to talk about mental

health 14 14

Other (WRITE IN) 15 15

REA

SON

FO

R R

EFU

SAL

(MU

LTIC

OD

E O

K)

REC

ON

TAC

T

Do not recontact 16 16

Composition: Elderly adult household 17 17

Family with children 18 18 Other 19 19

Sex of person refusing: Male 20 20 Female 21 21

Ethnic Origin: White 22 22

ESTI

MA

TED

C

HA

RA

CTE

RIS

TIC

S

Other 23 23

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* DWELLING INFORMATION AND SELECTION *

Q1. Code property type of printed address:

House/bungalow – detached

House/bungalow – semi-detached

House/bungalow – mid terrace

House/bungalow – end terrace

Purpose built flat/maisonette/tenement(s) - building less than six floors

Purpose built flat/maisonette/tenement(s) - building six or more floors

Conversion flat/maisonette(s)

Hostel or bed and breakfast

Other (WRITE IN)

Q2. Does the precise address printed on the contact sheet consist of just one house, or flat?

(IF NOW PART OF A LARGER PROPERTY CONSIDER THAT LARGER PROPERTY)

Yes GO TO HOUSEHOLD SELECTION (Q4)

No – more than one house or flat ASK Q3

Q3. Write in total number of houses/flats, then select one at random using the Kish

Selection on page 3, and write in selected number:

Total number of

houses/flats Number selected

from Kish Selection

* INTRODUCTION *

Good morning/afternoon/evening. My name is …. from Ipsos MORI, the research company. You should have had a letter recently about an important survey we are conducting for the Scottish Executive (SHOW COPY OF LETTER). The interview will take about 30 minutes. I would like to assure you that all the information we collect will be kept in the strictest confidence by Ipsos MORI, and used for research purposes only. It will not be possible to identify any particular person, household, or address in the results.

* HOUSEHOLD SELECTION * ALL Q4. Can I just check, how many households live here? By household I mean a person, or group of

people who normally live here, who share a living or sitting room, or share at least one meal a day.

One household only GO TO Q6

More than one household ASK Q5

Q5. Ask respondent for details of households – write in total number of households, then select one

at random using the Kish Selection on page 3, and write in selected number

Total number of

households Number selected

from Kish Selection

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* RESPONDENT SELECTION * ASK ALL Q6. I’d like to interview one of the people aged 16 or over who live in this household, and in

order to choose fairly, I’d like to ask a few questions. Can you tell me how many people (aged 16 or over) currently live here as part of this household?

One only COMPLETE INTERVIEW

Two or more COMPLETE DETAILS BELOW AND Q7

Total number of

household members 16+

Number selected from

Kish Selection (FILL IN NAMES BELOW AND SELECT USING KISH

SELECTION ON PAGE 3)

Q7. We have a special way of selecting which person to interview and in order to choose fairly can you please tell me the first name or initial of each member of the household (aged 16 or over). LIST NAMES/INITIALS BELOW IN ALPHABETICAL ORDER

HOUSEHOLD MEMBER INCLUDE:FIRST NAME OR INITIALCODE NUMBER People (normally living here) away for less than

6 months 1 People away at work for whom this is main addre 2 Boarders and lodgers 3 4 EXCLUDE 5 Spouses separated and no longer resident 6 People away for 6 months or more 7 People 16+ living elsewhere for study/work 8 9 NO SUBSTITUTIONS ONCE SELECTED

CONTINUE WITH INTERVIEW WITH SELECTED HOUSEHOLD

MEMBER; KISH GRID - USE KISH GRID BELOW FOR SELECTIONS AT Q3, Q5 AND Q7. INSTRUCTIONS: SELECT NUMBER USING GRID: Ring the last digit of the four-digit address number in the left hand column, and ring the digit in the first row corresponding to the number of possible units you are selecting from. Read along the circled row and down the circled column, where they meet gives the number of the selected unit or person.

117

Q3: NUMBER OF HOUSES/FLATS AT ADDRESS Q5: NUMBER OF HOUSEHOLDS Q7: No. OF ADULT HOUSEHOLD MEMBERS

PLEASE RING

1 2 3 4 5 6 7 8 9

0 1 1 2 1 3 6 5 4 7 LAST 1 1 2 3 4 1 1 6 5 9 DIGIT 2 1 1 1 3 4 3 3 1 4 OF 3 1 2 2 1 5 4 7 6 8 ADDRESS 4 1 1 3 2 2 5 2 3 6 NUMBER 5 1 2 1 4 3 2 1 7 2 6 1 1 2 3 1 6 4 2 1 7 1 2 3 1 4 1 5 8 3 8 1 1 1 2 5 3 6 4 5 9 1 2 2 4 2 4 3 5 7

NOTES If more than 9 houses/flats (for Q3), households (for Q5), or adults (for Q7) at address call office for instructions. Continue with screening procedure at next question after selection. If situation is complex, or you are at all unsure of how to count houses/flats, households, or householders, contact head office for guidance. Once a selection has been made no substitutions are allowable.

118

ANNEX D: QUESTIONNAIRE CHANGES FOR THE 2006 SURVEY D.1 The main refinements and additions which were made to the questionnaire for the 2006 survey were as follows:

• the existing question on self-reported general health was changed to harmonise with the comparable measure from the Scottish Health Survey

• for the questions focusing on positive and negative influences on mental health, the preamble was altered slightly to focus more specifically on the respondents’ own experiences. Additionally, the questions were left open-ended to speed up the coding process and reduce the number of responses coded as ‘other’. The original precode lists for these questions formed the basis of the frames used for coding but, as in 2004, some of the response categories were refined

• the GHQ12 was supplemented with the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). Whereas the former is designed to detect possible psychiatric morbidity, WEMWBS is a new measure designed specifically to assess mental wellbeing

• in the questions which ask respondents about their experience of specific mental problems, post-traumatic stress disorder was added to the lists of options

• new questions were added to explore whether people who have experienced a mental health problem have told others about that problem and whether they have ever chosen to avoid a social event because of the way they think people will treat them

• in the section on recovery from mental ill-health, two new questions were added focusing on factors that hinder recovery and messages of recovery received from a) health professionals and b) friends/family

• in the section on sources of information on mental ill-health, the item measuring awareness of specific campaigns, initiatives and promotional activity was extended to include those initiatives which had come on stream since 2004

• in the vignettes section, a new option - the circumstances in which Robert/Shona lives - was added to the lists of possible causes of the symptoms depicted

• Additionally, the question concerning whether Robert/Shona should have the same rights as other people was rephrased as it was felt that the original version was likely to be affected by social desirability bias, that is, the tendency for survey respondents to give answers which they deem to be socially acceptable

• finally a new question was added to the demographic section of the questionnaire to record household composition

D.2 Of course, these refinements and changes had significant implications for the length of the questionnaire. To keep the interview to the target length of 30 minutes, a number of other questions were deleted. For the most part the deleted items were questions which had proven to be of limited analytical value in 2004. The questions focused on:

• activities which people with a disability have difficulty managing on their own • attendance at social/leisure events and community/representative groups • the nature of any undiagnosed mental health problems experienced by respondents • situations in which respondents with personal experience of mental ill-health have

chosen not to disclose their problem. • respondents’ perceptions of media portrayal of people with mental health problems

119

• the perceived nature of the messages being conveyed by promotional materials

D.3 Cuts were also made to the demographic section of the questionnaire. In particular, the decision was taken not to classify respondents’ socio-economic status using NS-SEC23

which meant that the various questions from which this measure is derived could be deleted.

23 NS-SEC is an occupationally based classification which has been introduced to all official statistics and surveys to replace the use of Socio-Economic Groups (SEG). More information on the definition of NS-SEC can be found at www.statistics.gov.uk/methods_quality/ns_sec

120

ANNEX E: QUESTIONNAIRE MORI/J28801 Questionnaire No: Serial No1-5 OUO (6-9)

CARD 1 10 The Third National Scottish Survey of Public Attitudes to Mental Health, Mental

Wellbeing and Mental Health Problems

Sample Point Number:

() () () Sample point name:

INTRODUCTION/CONFIDENTIALITY Good morning, afternoon, evening. My name is …… from Ipsos MORI, the research organisation. You should have had a letter recently about an important survey we are conducting for the Scottish Executive (SHOW COPY OF LETTER). The interview will take about 30 minutes. I would like to assure you that all the information we collect will be kept in the strictest confidence, and used for research purposes only. It will not be possible to identify any particular individual or address in the results. Section A – General Health and Lifestyle A1. SHOWCARD A I’d like to start by asking some questions about your general

health and lifestyle. First of all, how is your health in general? Would you say it was… SINGLE CODE

Very good 1

Good 2

Fair 3

Bad 4

Very bad 5 Don’t know 6 ( )

A2 Do you have any long standing illness, disability or infirmity? By long-standing, I mean

anything that has troubled you over a period of time, or that is likely to affect you over a period of time? SINGLE CODE

Yes 1

No 2 ASK IF YES AT A2. OTHERS GO TO A5

121

A3 Does this illness, disability or infirmity limit your activities in any way? SINGLE CODE

Yes 1

No 2 A5 SHOWCARD B How long have you lived in this neighbourhood? By this

neighbourhood I mean within about 15 minutes walk of here? SINGLE CODE

Less than a year 1

One year, less than 2 years 2

Two years, less than five years

3

Five years, less than 10 years 4

10 years, less than 20 years 5

20 years or more 6 Don’t know/can’t remember 7 ( )

A6 SHOWCARD C How satisfied or dissatisfied are you with this neighbourhood as a

place to live? SINGLE CODE

Very satisfied 1

Fairly satisfied 2

Neither satisfied nor dissatisfied

3

Fairly dissatisfied 4

Very dissatisfied 5 Don’t know 6 ( )

A7 On average, how often do you see friends or relatives, who are not living with you?

Would you say… SINGLE CODE

On most days 1

Once or twice a week 2

Once or twice a month 3

Less often than once a month 4

Never 5 Don’t know 6 ( )

A10 Do you give up any time as a volunteer or as an organiser for any charities, clubs or

organisations (in an unpaid capacity)? SINGLE CODE ONLY

Yes 1

No 2 Don’t know 3 ( )

122

A11 A12

I am now going to describe two situations where people might need help. For each one, could you tell me if there is anyone you could ask for help? You are ill in bed and need help at home. Is there anyone you could ask for help? SINGLE CODE You are in financial difficulty and need to borrow some money to see you through the next few days. Is there anyone you could ask for help? SINGLE CODE

A23 A24 ( ) ( ) Yes 1 1

No 2 2 Don’t know 3 3 ( )

A13 If you had a serious personal crisis, how many people, if any, do you feel you could

turn to for comfort and support?

123

Section B – Mental Health and Wellbeing I’m now going to ask you some questions about your own emotions or how you feel about yourself - sometimes called mental health and wellbeing. B1 What sorts of things, if any, have a positive or good effect on your own emotions or

mental health and wellbeing? DO NOT PROMPT. PROBE FULLY

Don’t know ( )

B2 And what, if any things have a negative or bad effect on your own emotions or mental

health and wellbeing? DO NOT PROMPT. PROBE FULLY

Don’t know ( )

B3 SHOWCARD D Thinking about all those things that might affect your own emotions or

mental health and wellbeing, how much control, if any, do you feel you have over them? SINGLE CODE

Complete control 1

A good deal of control 2

Some control 3

A little control 4

No control at all 5 Don’t know 6 ( )

124

CASI SECTION ALTERNATE ORDER OF WEMWBS AND QB4-QB15 Below are some statements about feelings and thoughts WEMWBS© Please tick the box that best describes your experience of each over the

last two weeks

None of the time

Rarely

Some of the time

Often All of the

time

I’ve been feeling optimistic

about the future

1 2 3 4 5

I’ve been feeling useful 1 2 3 4 5 I’ve been feeling relaxed 1 2 3 4 5 I’ve been feeling interested

in other people1 2 3 4 5

I’ve had energy to spare 1 2 3 4 5

I’ve been dealing with problems well

1 2 3 4 5

I’ve been thinking clearly 1 2 3 4 5

I’ve been feeling good about myself

1 2 3 4 5

I’ve been feeling close to other people

1 2 3 4 5

I’ve been feeling confident 1 2 3 4 5

I’ve been able to make up my own mind about things

1 2 3 4 5

I’ve been feeling loved 1 2 3 4 5

I’ve been interested in new things

1 2 3 4 5

I’ve been feeling cheerful 1 2 3 4 5

The GHQ12 appeared here in the CAPI script. Due to copyright restrictions, the scale cannot be reproduced in its original form.

125

Section C – Mental Health Problems C1 SHOWCARD E I’m now going to read out some things people have said

about mental health problems. Taking your answer from this card, I’d like you to tell me how much you agree or disagree with each of these statements SINGLE CODE. RANDOM ORDER

Stro

ngly agre

e

Tend to

agree

Neither agree nor disagree

Tend to

disagree

Strongly disagree

Don’t

know

If I was suffering from mental health problems, I

wouldn’t want people knowing about it

1 2 3 4 5 6

The public should be better protected from people with

mental health problems

1 2 3 4 5 6

Anyone can suffer from mental health problems

1 2 3 4 5 6

I would find it hard to talk to someone with mental

health problems

1 2 3 4 5 6

People are generally caring and sympathetic to people

with mental health problems

1 2 3 4 5 6

People with mental health problems are often

dangerous

1 2 3 4 5 6

The majority of people with mental health problems

recover

1 2 3 4 5 6


1 2 3 4 5 6

People with mental health problems are largely to

blame for their own condition

1 2 3 4 5 6

126

C2 How common do you think it is for people to have mental health problems at some

stage in their lives? Out of 100 people in Scotland, how many do you think will have a mental health problem at some point in their lives? WRITE IN

Don’t know X

C3 From what you know has anyone close to you ever experienced a mental health

problem or not? SINGLE CODE

Yes 1


Refused 4

127

C4 SHOWCARD F From what you know, has anyone close to you ever been told by a

doctor or other health professional, that they had one or other of these kinds of specific mental health problems? Just read out the letters that apply. MULTICODE OK

Yes:

A Alzheimer’s disease/Dementia 1

B Anxiety disorder 2

C Depression 3

D Eating disorder (anorexia, bulimia)

4

E Manic depression (bipolar affective disorder)

5

F Nervous breakdown 6

G Obsessive/compulsive behaviour/disorder

7

H Panic attacks 8

I Personality disorder 9

J Phobias (e.g. agoraphobia) 0

K Post-natal depression X

L Schizophrenia Y

M Self-harm 1

N Severe stress 2 O Post traumatic stress disorder 3

P Other (PLEASE WRITE IN AND CODE ‘2‘)

4

Q Yes been told he/she had problem but don’t know what

it was called

6

None of these 7

Don’t know 8 ( )

Refused 9

C5 Have you ever personally experienced a mental health problem or not? SINGLE CODE

Yes 1


Refused 4

128

C6 SHOWCARD G Have you ever been told by a doctor or other health professional, that

you personally have had one or other of these kinds of specific mental health problems? Just read out the letters that apply. MULTICODE OK

Yes:

A Alzheimer’s disease/Dementia 1

B Anxiety disorder 2

C Depression 3

D Eating disorder (anorexia, bulimia)

4

E Manic depression (bipolar affective disorder)

5

F Nervous breakdown 6

G Obsessive/compulsive behaviour/disorder

7

H Panic attacks 8

I Personality disorder 9

J Phobias (e.g agoraphobia) 0

K Post-natal depression X

L Schizophrenia Y

M Self-harm 1

N Severe stress 2

O Post traumatic stress disorder 3

P Other (PLEASE WRITE IN AND CODE ‘2‘)

4

Q Yes been told had problem but don’t know what it was

called

5

None of these 6

Don’t know 7

Refused 8

C6A SHOWCARD H Have you told anyone about your mental health problem, apart from

your doctor or any other health professionals? MULTICODE OK

A Yes, I have told family and/or friends

1

B Yes I have told my manager/boss at work

2

C Yes, I have told other colleagues at work

3

D Yes, I have told a tutor/member of staff at college/university/other

course

4

E Yes I have told other people I don’t know well

5

F No I have told no-one 6

129

ASK ALL WHO SAY YES AT C5 OR ANY CODE (1-Y & 1-3) AT C6. OTHERS GO TO C8B C8 SHOWCARD I Have you experienced any of the following as a result of other people’s

attitudes towards your mental health problem(s)? Just read out the letters that apply MULTICODE

A (“UNABLE TO” DELETED IN FIRST 4 OF THESE

CODES) Discouraged from participating in social events,

such as going out with friends

1

B Discouraged from participating in children’s

school based activities

2

C Discouraged from taking part in local community life

3

D Discouraged from going on holiday

4

E Been refused a job 5

F Been overlooked/refused for promotion

6

G Verbally abused in public 7

H Verbally abused within the family

8

I Physically abused in public 9

J Physically abused within the family

0

K Graffiti or rubbish targeted at the home

X

L Experienced discrimination at work

Y

Other (PLEASE WRITE IN AND CODE ‘ ‘)

1

None of these 2

Don’t know 3 ( )

Refused 4

ASK ALL WHO SAY YES AT C5 OR ANY CODE (1-Y & 1-3) AT C6 C8B Have you ever chosen to avoid a social event because of the way you think people will

treat you because of your mental health problem(s)? SINGLE CODE

Yes

No

Don’t know/can’t remember

130

ASK ALL WHO SAY YES AT C5 OR ANY CODE (1-Y & 1-3) AT C6 C10

SHOWCARD J Thinking again about the mental health problem(s) you have experienced, which two or three, if any, of the following were most important in supporting your recovery? CODE UP TO THREE C 11 DELETED

C10 ( ) A Finding out more about

mental health (e.g. through support groups, leaflets, web

information etc.)

1

B Medication 2

C Other forms of treatment/therapy (e.g.

psychology, counselling, alternative treatments, support

groups)

3

D Developing my own coping strategies

4

E Support from colleagues/work

5

F Support from family or friends

6

G Support from people with a similar experience

7

H Having something worthwhile to do during the day (e.g.

work, volunteering education, hobbies etc.)

8

I Having a chance to contribute and be valued

9

J Having others believe in me 0

K Having belief in myself X

Other (PLEASE WRITE IN

AND CODE ‘Y’)Y

L I don’t believe myself to be in recovery

1

None of these 2

Don’t know 3 ( )

131

C10B

SHOWCARD K And what factors, if any, have most hindered your recovery? MULTICODE OK

C10B ( ) A Not acknowledging I had a

problem1

B Not feeling able to tell people about my mental health

problem

2

C Negative attitudes of people around me

3

D Not being able to access appropriate services or

treatment

4

E Not getting the right medication

5

F Continuing to experience symptoms

6

G Lack of support or understanding from family or

friends

7

H Lack of support or understanding from

colleagues/work

I Lack of access to employment, education or

training opportunities

8

Not understanding what was going on

9

Other (PLEASE WRITE IN AND CODE ‘0‘)

0

None of these X

Don’t know Y

ASK ALL WHO SAY YES AT C5 OR ANY OR ANY CODE (1-Y & 1-3) AT C6 C12 What does recovery mean to you? DO NOT PROMPT. MULTICODE OK

Having a satisfying and fulfilling life

1

Taking charge of my life again

2

Getting back to normal 3

Fewer symptoms 4

132

Feeling able to cope in general

5

Getting back to work 6

Taking up training or education opportunities

7

No longer needing treatment or services (including

medication)

8

Getting involved in activities I enjoy

9

Feeling more able to socialise 0

Getting more sleep X Other (PLEASE WRITE IN

AND CODE ‘ ‘)y

None of these 1

Don’t know 2 ( )

C12B

SHOWCARD L To what extent have the professionals you have come into contact with (nurses, doctors, support workers etc.) given you a positive or negative message about your recovery? SINGLE CODE

Completely positive

Mainly positive

Mixed

Mainly negative

Completely negative

Don’t know

C12C

SHOWCARD L AGAIN To what extent have the people around you (family, friends, colleagues, carers, etc) given you a positive or negative message about your recovery? SINGLE CODE

Completely positive

Mainly positive

Mixed

Mainly negative

Completely negative

Don’t know

133

Section D – Sources of information about mental health problems There are many ways in which people might form an impression of what mental health problems are. I’m interested to know how you have gained your understanding of mental health problems, and how they affect people’s lives. D1. D2.

SHOWCARD M Taking your answers from this card, which, if any, of the following have been important in forming your impression? MULTICODE OK Just read out the letters ASK IF MORE THAN ONE MENTIONED AT D1. OTHERS GO TO D3 SHOWCARD M AGAIN Which one of these sources would you say was the most influential for you? SINGLE CODE

D1 D2 ( ) ( ) A Personal contact or personal

experience 1 1

B Work 2 2

C School/college 3 3

D National newspapers 4 4

E Local newspapers 5 5

F Books/leaflets/magazines 6 6

G Television news and current affairs programmes

7 7

H Television soaps 8 8

I Other TV 9 9

J Radio 0 0

K Word of mouth X X

L Health professionals Y Y

M Internet 1 1

Other (PLEASE WRITE IN AND CODE ‘ ‘)

2 2

None of these 3 3

Don’t know 4 4 ( )

D4 SHOWCARD N In the last year, have you seen, read or heard an advert or promotion

about mental health/mental health problems in any of these places? MULTICODE OK

No have not (NOT ON SHOWCARD)

1

Yes, seen advert in newspaper 2

Yes, seen advert in magazine 3

Yes, saw leaflet at doctors/other surgery

4

Yes, seen advert on billboard/bus etc

5

134

Yes, seen advert on television/at cinema

6

Yes, heard advert on radio 7

Yes, on the internet 8

Yes, but not sure whether seen, read, or heard

9

Don’t know 0 ( )

D6 There have been a number of campaigns, initiatives and promotional activity

regarding mental health in Scotland. Have you heard of any of the following or not? READ OUT. SINGLE CODE

Yes No Don’t know Choose Life, the national

strategy and action plan to prevent suicide

1 2 3

See Me….The national anti-stigma campaign

1 2 3

The Breathing Space telephone advice line for people experiencing low

mood or depression

1 2 3

Mental Health First Aid 1 2 3

The Scottish Recovery Network

1 2 3

ASIST suicide prevention training

1 2 3

ArtFull – the initiative to promote the arts in

improving mental health and wellbeing

1 2 3

HeadsUpScotland – the national project for children

and young people’s mental health

1 2 3

Doing Well by People with Depression

1 2 3

‘Well’ magazine 1 2 3

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Section E – Examples of mental health problems Scenarios This card describes someone who has a mental health problem – please read through it or I can read it out if you prefer. I’d then like to ask you some questions about what you think might be wrong and how the person can be helped. E1 SHOWCARD O In your opinion, how likely or unlikely is it that

Robert’s/Shona’s (CAPI: TO USE NAME FROM VIGNETTE IN REST OF SECTION) situation might be caused by each of the following? SINGLE CODE. READ OUT. ROTATE ORDER. TICK START

Very likely

Somewhat likely

Somewhat

unlikely

Very unlikely

Don’t know

Robert’s/Shona’s own character or personality

1 2 3 4 5

Chemical imbalance in the brain

1 2 3 4 5

The way Robert/Shona was brought up

1 2 3 4 5

Stressful or disturbing events in Robert’s/Shona’s life

1 2 3 4 5

Genetic or inherited problem 1 2 3 4 5

Abuse Robert/Shona suffered as a child

1 2 3 4 5

Fate 1 2 3 4 5

Physical illness 1 2 3 4 5

Robert/Shona’s own fault 1 2 3 4 5

The circumstances in which Robert/Shona lives

1 2 3 4 5

E2 SHOWCARD P Say it was possible for any of the people on this card to help

Robert/Shona. Who would be the three best people to do this? CODE UP TO THREE

Someone in the family 1

A friend or neighbour 2

A nurse 3

A home help/carer/care assistant

4

A psychiatrist 5

A psychologist 6

A family doctor 7

A social worker 8

A qualified counsellor 9

A voluntary organisation or charity

0

Someone with the same X

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problem Someone else Y

No one 1 Other (PLEASE WRITE IN

AND CODE ‘ ‘)2

None of these 3

Don’t know 4 ( )

E3 SHOWCARD Q If all of the options on this card were possible, where do you think it

would be best for Robert/Shona to live? Just read out the letter that applies SINGLE CODE. JUST READ OUT THE LETTER THAT APPLIES

A In their own (or family’s) home

1

B In special housing with professional support in the

community

2

C In a residential or nursing home

3

D In hospital 4 Other PLEASE WRITE IN

AND CODE ‘5’5

Don’t know 6 ( )

E4 SHOWCARD R In your opinion, how likely is it that Robert/Shona would do something

harmful or violent to (i) him/herself (ii) other people? SINGLE CODE

Self Others

Very likely 1 1

Somewhat likely 2 2

Somewhat unlikely 3 3

Very unlikely 4 4 Don’t know 5 5 ( )

E5 SHOWCARD S How willing would you be to….? READ OUT. ROTATE

ORDER. TICK START

Very willing

Fairly

willing

Neither

willing nor

unwilling

Fairly

unwilling

Very unwilling

Don’t

know


1 2 3 4 5 6


1 2 3 4 5 6

137


1 2 3 4 5 6

Start working closely with Robert Shona

1 2 3 4 5 6

Have Robert Shona marry into the family

1 2 3 4 5 6

Do Robert/Shona a favour if they asked you to

1 2 3 4 5 6

Have Robert/Shona provide childcare for someone in your

family (e.g. babysitting, childminding)

1 2 3 4 5 6

E6 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? SINGLE CODE

Very likely 1

Fairly likely 2

Not very likely 3

Not at all likely 4 Don’t know 5 ( )

E7 SHOWCARD T (AND THE SCENARIO SHOWCARD) The description I read out/you read

earlier for Shona/Robert was designed with one particular mental health problem in mind. Which one of these do you think it is most likely to be? SINGLE CODE

Alzheimer’s disease/Dementia 1

Anxiety disorder 2

Depression 3


4


5

Nervous breakdown 6

Obsessive/compulsive behaviour/disorder

7

Panic attacks 8

Personality disorder 9

Phobias (e.g. agoraphobia) 0

Post-natal depression X

Schizophrenia Y

Self-harm 1

Severe stress 2

Post traumatic stress disorder 3

Other 4

Don’t know 5

Refused 6

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Section F – Demographic information F1 How old are you? ENTER AGE — ESTIMATE IF NECESSARY (INCLUDE A CODE TO

BE MARKED WHEN ESTIMATE USED)

16-24 1

25-34 2

35-44 3

45-54 4

55-59 5

60-64 6

65-74 7

75+ 8

F2 GENDER

Male 1

Female 2

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F3 SHOWCARD U. Ethnicity. Which one of these best describes you? SINGLE CODE

ONLY

White

A Scottish 1

B Other British 2

C Irish

3

D Any other White background

4

Mixed

E Any mixed background 5

Asian, Asian Scottish, or Asian British

F Indian 6

G Pakistani 7

H Bangladeshi 8

I Chinese 9

J Any other Asian background 0

Black, Black Scottish, or Black British

K Caribbean X

L African Y

M Any other Black background 1 F4 HOUSEHOLD COMPOSITION. And how many people aged under 16 live in

your household?

0 1

1 2

2 3

3 4

4 5

5+ 6 F4B HOUSEHOLD COMPOSITION. And how many people aged 16 and over live in

your household?

0 1

1 2

2 3

3 4

4 5

5+ 6

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F5 SHOWCARD V. In which of the following income categories does your net household

income fall, that is after tax and other deductions? Just read out the letter from the card.

Weekly Annually

A Under £60 per week Under £3,120 per year 1

B £60 and less than £100 £3,120 and less than £5,200 2

C £100 and less than £200 £5,200 and less than £10,400 3

D £200 and less than £300 £10,400 and less than £15,600 4

E £300 and less than £400 £15,600 and less than £20,800 5

F £400 and less than £500 £20,800 and less than £26,000 6

G £500 and less than £600 £26,000 and less than £31,200 7

H £600 and less than £700 £31,200 and less than £36,400 8

I £700 and above £36,400 or more 9

Refused 0

Don’t know X

F6 SHOWCARD W. How easy or difficult do you find it to manage on your household’s income?

Very easy 1

Fairly easy 2

Manageable 3

Fairly difficult 4

Very difficult 5

Don’t know 6

F7 SHOWCARD X Using this card, please tell me which is the highest educational or professional qualification you have obtained. CODE ALL THAT APPLY.

School Leaving Certificate, new National Qualification

Access Unit

1

O Grade, Standard Grade, GCSE, CSE, Senior

Certificate or equivalent

2

GSVQ Foundation or Intermediate, SVQ Level 1 or

2, SCOTVEC Module or equivalent, New National

Qualification Access 3 Cluster, Intermediate 1 or 2

3

SEC Higher Grade/New National Qualification Higher

4

141

or Advanced Higher/CSYS/A level, Advanced Senior

Certificate or equivalent GSVQ Advanced, SVQ Level

3, ONC, OND, SCOTVEC National Diploma or

equivalent

5

City and Guilds 6

HNC, HND, SVQ Levels 4 or 5 or equivalent

7

First Degree, Higher degree 8

Professional qualifications e.g. teaching, accountancy

9

None of these 0

F8 SHOWCARD Y. Which of these apply to you? CODE ALL THAT APPLY

A In paid work 1

B Local or government training scheme (GTS)

2

C Modern Apprenticeship 3

D Registered unemployed/signing on for

JSA

4

E Not registered but seeking work

5

F At home/not seeking work 6

G Long-term sick or disabled 7

H Retired 8

I Full-time education 9

J Carer (for example, of an elderly relative person or

someone with a permanent sickness or disability)

0

Other (PLEASE SPECIFY) X

F9 Please tell me, does your household own or rent this accommodation? SINGLE CODE

Owns with mortgage/loan 1

Owns outright 2

Rents from local authority 3

Rents from housing association

4

Rents privately 5

Rents – other 8

Rent free 0

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F10 Is there a car or van normally available for use by you or any members of your

household?

Yes 1

No 2

F21 Thank you very much for your help with the survey. Finally, would you be willing to be

re-interviewed on a future Scottish Executive survey?

Yes 1

No 2

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ANNEX F : MULTIVARIATE ANALYSIS TECHNIQUES F.1 Regression analysis is a technique used to identify factors that contribute to an outcome and to give an indication of the relative strength of these factors. The most common form of regression is linear regression, which is analogous to drawing a ‘line of best fit’ through the data. The regression process considers each one of the contributory factors under consideration and systematically tests combinations of those factors to find the collection of factors that most accurately defines the outcome. In the context of the 2006 survey, regression analysis was used to identify which variables have the strongest relationship with attitudes to mental ill-health. F.2 Segmentation analysis is a way of simplifying survey questions into a smaller number of themes or ‘factors’ by grouping together items that are answered in similar ways. The process involves factor analysis to identify the common themes, followed by cluster analysis to segment the sample into groups based on these themes. The demographic composition of each of the typologies can then be analysed. Segmentation analysis was used to provide a fuller picture of responses to the attitudinal statements presented in the survey, including the extent to which responses vary among different groups of respondents. F.3 Correlation analysis compares two variables and assesses to what extent (i.e. how strongly) they are related to each other. The best way to visualise correlation is in terms of a scatterplot. The x-axis represents one variable and the y-axis represents another variable. Each respondent has a score on variable 1 and a score on variable 2, so each respondent can be represented as a point on this scatterplot. The pattern of points formed by plotting each respondent will dictate the strength and direction of correlation. A strongly correlated pair of variables will form a pattern resembling a straight line. The orientation of the line will dictate the direction of the correlation. If the line slopes upwards (i.e. from bottom-left to top-right), then the correlation is positive. If the slope is downwards, then the correlation is negative. However, as with regression analysis, correlation analysis can identify only an association between variables; it cannot tell us if the association is causal, or the direction of causality. F.4 The aggregation of responses across variables provides another means of generalising about the ways in which particular types of questions are answered by different groups of respondents. Typically, it involved allocating a score to respondents which reflects their pattern of responding across a number of questions, and then considering to what extent higher and lower scores are correlated with other attitudes and behaviours. In the present study, this approach was used in a number of different ways. For example, respondents were given a ‘social engagement’ score based on their answers to the questions concerning their informal support networks and civic participation. Similarly, they were given a ‘social distance’ score which reflected their responses to the battery of questions exploring their willingness to interact with someone displaying symptoms of mental ill-health.

144

ANNEX G: STATISTICAL SIGNIFICANCE AND RELIABILITY Statistical significance G.1 The formula used for calculating significant differences between sub-groups is as follows: The standard deviations for two sub-groups are calculated as SD1 and SD2 1) Calculate an “overall” or “pooled” SD for the two groups together. This is very close to the weighted average; weighted by the relative sizes of the sub-groups in the sample.

)2().1().1(

21

222

211

−+−+−

=nn

SDnSDnSDp

2) Use this pooled measure to calculate the Standard Error of the Difference (SED) between the sub-group means, i.e.:

21

11nn

SDpSED +=

3) Divide the difference between the sub-groups scores that you observe, by the SED. If the size of this result (technically referred to as the “t-score”) is greater than 1.96 (i.e. either less than –1.96 or greater than +1.96), then the difference is statistically significant at the 95% confidence level. In other words, there is sufficient evidence that scores in the underlying population are different for the two sub-groups. Thus:

( )SED

xxt 21 −

=

Statistical Reliability G.2 The respondents to the questionnaire are only a sample of the total ‘population’. We cannot therefore be certain that the figures obtained are exactly those we would have if everybody had been interviewed (the ‘true’ values). However, we can predict the variation between the sample results and the ‘true’ values from a knowledge of the size of the samples on which the results are based and the number of times that a particular answer is given. G.3 The confidence with which we can make this prediction is usually chosen to be 95% - that is, the chances are 19 in 20 that the ‘true’ value will fall within a specified range. The table below illustrates the predicted ranges for different sample sizes and percentages results at the ‘95% confidence interval’, based on a random sample.

145

Table G.1: Predicted ranges for different sample sizes at the 95% confidence interval

Size of sample on which survey result is based

Approximate sampling tolerances applicable to percentages at or near these levels

10% or 90%

+

30% or 70%

+

50%

+

100 interviews 6 9 10




1,000 interviews 2 3 3

1,216 interviews 2 3 3

Source: Ipsos MORI

G.4 For example, on a question where 50% of the people in a sample of 1,216 respond with a particular answer, the chances are 95 in 100 that this result would not vary by more than four percentage points, plus or minus from a complete coverage of the entire population using the same procedures. However, while it is true to conclude that the “actual” result (95 times out of 100) lies anywhere between 46% and 54%, it is proportionately more likely to be closer to the centre of this band (i.e. at 50%).

146

G.5 Tolerances are also involved in the comparison of results from different parts of a sample. A difference, in other words, must be of at least a certain size to be considered statistically significant. The following table is a guide to the sampling tolerances applicable to comparisons. Table G.2: Sampling tolerances

Size of samples compared Differences required for significance at or near percentage levels

10% or 90%

+

30% or 70%

+

50%

+

100 and 100 8 13 14

200 and 200 6 9 10

200 and 400 5 8 9

200 and 500 5 8 8

500 and 500 4 6 6

700 and 300 4 6 7

700 and 400 4 6 6

1,000 and 100 8 13 14

Source: Ipsos MORI

Table G.3: Demographic sub-group comparisons

Size of samples compared Differences required for significance at or near percentage levels

10% or 90%

+

30% or 70%

+

50%

+

Males vs. females ( 529 vs. 687)

4 5 6

Age 16-24 vs. 65-74 (108 vs. 177)

7 11 12

Easy to manage on income vs. difficult (630 vs. 156)

5 8 9

Good or very good general health vs. bad or very bad general health (882 vs. 93)

6 10 11

Source: Ipsos MORI

147

ANNEX H: OMISSION OF GHQ12 QUESTIONS FROM SURVEY SCRIPT FOR PART OF THE FIELDWORK PERIOD Background to the omission

H.1 The survey questionnaire includes a self completion module comprising two batteries of questions. The first of these is the Warwick-Edinburgh Mental Well-being Scale (WEMWBS), a measure of positive mental health. The second is the GHQ12 which screens for possible psychiatric morbidity. The WEMWBS battery is a fairly new measure and was included in the survey for the first time in 2006. The GHQ12 was included in the 2004 and 2006 surveys.

H.2 To minimise potential question order effects, the decision was taken to randomise the order in which the two batteries were presented to respondents and include an administrative variable in the survey script which would record the order for each case.

H.3 However, shortly after the start of fieldwork, it came to Ipsos MORI’s attention that the administrative variable had been omitted from the CAPI script. To rectify this, the script was withdrawn and a new version created which included the missing variable. As part of this process a test version of the new script was created in which all but the first two items in the GHQ12 battery were removed to speed up the testing process – there was no need to go through all of the GHQ12 questions to establish that the new administrative variable was working properly. Unfortunately, the deleted questions were not then added back into the new script and the incomplete version was released to interviewers.

H.4 Consequently, respondents who were interviewed using the new version of the script were presented with only the first two questions from the GHQ12 component. In terms of sample sizes, this meant that of the 973 respondents who agreed to complete the self-completion module (as usual, a proportion refused this exercise), only 460 were presented with the full GHQ12 section, while 513 people were presented with the first two questions only. Implications H.5 In several respects the loss of the GHQ12 data does not affect the extent to which the survey can meet the objectives set for it - for example, to track awareness and understanding of mental health and wellbeing, and attitudes towards people with mental health problems. In other ways, however, the loss is significant. In the 2004 survey the GHQ12 was found to be an important discriminator in many aspects of the study. While results for the individual GHQ12 items were included in the 2004 report, the battery’s primary use was in the form of a binary variable constructed from respondents’ responses to each of the component items. Depending on their responses to each of the GHQ12 questions, respondents were given a GHQ12 score ranging from zero to 12. These scores were then recoded into a binary variable, 0-3 and 4+. Scores of 0-3 indicate no/few signs of possible mental health problems (‘low mental ill-health score’), and scores of 4+ were labelled as indicating possible mental health problems (‘high mental ill-health score’).

H.6 The number of cases rated as ‘high mental ill-health score’ in the 2006 survey is 81 which is considerably lower than it would have been had the omission not occurred. The small sample size restrained Ipsos MORI’s ability to undertake more detailed analysis of this group.

H.7 The omission also meant that there was a reduced number of cases for an analysis of the way people responded to the two self-completion modules, and the relative predictive powers of the

148

two. However, it remains true that there were sufficient numbers to draw a conclusion about this relationship. Options for the way forward

H.8 The survey Advisory Group, together with Ipsos MORI, met to discuss the way forward in light of the GHQ12 omission. Four main options were considered. Three of these options focused on ameliorative action, namely, recontacting the respondents concerned, imputation, and conducting the whole survey afresh using a new sample. The fourth option was to take no ameliorative action. Option 1: Recontacting respondents

H.9 This approach would have involved going back to those respondents who were not presented with the full GHQ12 module, with a view to gathering the missing data and thus plugging the gap. During the assessment of this option, a number of issues were discussed.

H.10 The first issue related to the likely reach of the exercise. As part of the main survey interview, Ipsos MORI obtained permission to return to conduct further research with most of the sample – a requirement under MRS guidelines - and typically around 75% agree to this. Of these people, it was anticipated that successful re-interviews could be achieved with around 60%, depending on the method used and the period devoted to the exercise (see below). This suggested that it would be possible to ‘plug the gap’ in around 230 cases. Members of the Advisory Group felt that the addition of 230 cases to the existing 460 would not lead to a significant improvement in statistical reliability for any resulting analyses, particularly since the main significance of the GHQ module is its ability to identify a relatively small subset of the sample who exhibit particular characteristics (discussed further below).

H.11 A second key consideration was that the GHQ12 module asks people to report on their feelings ‘recently’, and this raised issues about the viability of gathering this information over 8 weeks after the main attitudinal data have been gathered. The user manual for the GHQ12 module explicitly says that in ‘two stage studies’ (which this would effectively become) the GHQ data should be gathered as soon as possible after the rest of the interview “since the GHQ is designed to detect relatively acute changes in state, many of which are short-lived, the expected effect of delay is that a greater proportion of high scoring respondents will be rated as non-cases on subsequent interview, that is, will be regarded as false positives”24.

H.12 In terms of possible methods of recontacting respondents, 3 options were identified: a self completion, telephone or face to face approach. The main issues discussed with regard to each were as follows:

• Self-completion – contact by post – In this approach, a short booklet would be sent to respondents, incorporating the WEMWBS and GHQ12 questions (with some kind of explanation). These would have had to be individually numbered in order that they could be tied back to the original dataset. Although the questionnaire could be addressed to the relevant member of the household, it would be impossible to ensure that the same person completed it. The response rate would be likely to be fairly low, perhaps 45%-50%, and we might expect differential response rates from the sample, perhaps related to their

24 ‘A users guide to the General Health Questionnaire’ Goldberg & Williams, published by nferNelson, 1988

149

mental wellbeing, among other factors. Ipsos MORI reckoned that approximately 4 weeks would be required to undertake this work

• Telephone –Ipsos MORI obtained telephone numbers for around 76% of the sample and, anticipated that it could achieve a response rate of around 60% using repeated calls. However, it was anticipated that there would be some difference in the way that people responded to the questions over the telephone (in part because it would no longer be self-completion), compared with other modes. Ipsos MORI estimated that approximately 3 weeks would be required to undertake the exercise by telephone.

• Face-to-face – this method would have provided the closest match to the original study. A short self-completion module could be compiled and multiple calls at sample members’ homes could have resulted in the achieval of interviews with around 70% of the original respondents who indicated a willingness to be re-contacted. Ipsos MORI estimated that it would take approximately 6 weeks to prepare for this work and to undertake the fieldwork.

H.13 Of these three methods, the face-to-face approach was the preferred option among the Advisory Group because it was likely to achieve the largest sample and to be the closest match to the original study. However, the Group recognised that the time required to undertake the face to face fieldwork would cause a significant delay in the study timetable. Option 2: Imputation H.14 It is not uncommon in complex datasets to have some variables incomplete (perhaps because of item refusal) and to need to ‘impute’ responses on the basis of other responses in the survey and the way in which other similar respondents have answered questions. Ipsos MORI proposed this as a possible option. However, members of the Advisory Group expressed concern that there was lack of appropriate variables upon which to base the imputation, and suggested the number of missing variables was too large to make imputation feasible. Option 3: Starting the survey afresh H.15 The third option considered by the Advisory Group was to start the survey afresh using a new sample. Although this was undoubtedly the ‘purest’ of the 4 options considered, it would have resulted in a considerable delay to the study timetable. Option 4: Taking no ameliorative action H.16 Key to the decision as to whether taking no ameliorative action was viable, was an assessment of the quality of the data that had been collected using the second (incomplete) version of the script. If, upon analysis, the second sample appeared in some way different to the first sample - either in attitudinal or behavioural terms - it would have had to be assumed that there was a non-response bias in the sample which undermines the reliability of the data. To test this, Ipsos MORI conducted a comparative analysis aimed at identifying any significant differences between the key sub-samples in the data. The analysis compared the responses of the two samples on several key variables selected by the Advisory Group, namely:

• WEMWBS (mean scores)

• QB4 and QB5- first two items in the GHQ12 which were presented to all respondents:

o QB4 asks: Have you recently been able to concentrate on whatever you are doing?

150

o QB5 asks: Have you recently lost much sleep over worry?

• QC1 – 9 attitudinal statements (presented after the self-completion section)

• QC3 – Knowing someone who has experienced a mental health problems

• QC5 – Personal experience of mental health problems

H.17 The results showed that there were no significant differences between the samples on the following measures:

• WEMWBS

• QB4 and QB5 - the first two items in the GHQ12

• QC3 Knowing someone who has experienced a mental health problem

• QC5 Personal experience of mental health problems

H.18 And of the 9 attitudinal items (QC1) there were no significant differences for the following 6 statements:

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

• Anyone can suffer from mental health problems

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

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

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

• People with mental health problems are often dangerous

H.19 However, statistically significant differences were evident for the following 3 statements (reference to “positive” and “negative” refers to absence or presence of stigmatising attitudes):

• If I had a mental health problem, I wouldn’t want people knowing about it - Those who were not offered the full GHQ12 module are more likely to agree with this statement

• I would find it hard to talk to someone with mental health problems – Those who were not offered the full GHQ12 are more likely to disagree

• The majority of people with mental health problems recover – Those who were not offered the full GHQ12 module are more likely to agree

H.20 As there were no statistically significant differences between the two samples on the bulk of these measures – and that the significant differences that did exist on the three attitude statements were not internally consistent - both Ipsos MORI and the Advisory Group members concluded that the second sample did not display any systematic bias.

H.21 Another key question regarding the quality of the existing data was whether the number of respondents for whom full GHQ12 data has been collected was sufficient to allow for meaningful analyses. As already noted, only 460 people were presented with the full GHQ12 module. While this had some implications for the level of sub-group analysis that can be conducted on the data, the number of cases at the aggregate level was sufficient to compare the views of those with ‘high’ and

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‘low mental ill-health score’ and for a comparative analysis of responses to the GHQ12 and WEMWBS. Decision on the way forward and summary of rationale

H.22 On the basis of the various considerations set out above, it was decided to recommend to relevant Deputy Directors at the Scottish Executive that no ameliorative action be taken to address the omission. The over-arching rationale for this was that each of the alternative options was felt to carry significant disadvantages which would outweigh the problem of the missing data. Additionally, the existing data was felt by both the Advisory Group and Ipsos MORI to be of sufficiently high quality as to provide reliable GHQ12 data, amenable to aggregate level analysis. The recommendation was accepted.

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ANNEX I: ADDITIONAL MULTIVARIATE ANALYSES UNDERTAKEN 1) Analysis of the relationship between the number of positive and negative influences on mental wellbeing mentioned by respondents, and their mental health. I.1 Previous research has shown that the absence of positive influences on mental wellbeing, rather than the presence of negative influences, is crucial in predicting suicidal behaviour25. Accordingly, analysis was undertaken to explore whether there was a relationship between the number of positive and negative influences mentioned by respondents, and their mental health as measured by the GHQ12 and WEMWBS.

I.2 For the purpose of the analysis two new continuous variables were created: one representing the total positive number of influences mentioned by each respondent (QB1), and the other representing the total number of negative influences mentioned (QB2). Zero-order correlational analysis was then undertaken to explore i) the relationship between the number of positive influences that respondents mention and their mental health (as measured by both the GHQ12 and WEMWBS), and ii) the relationship between the number of negative influences that respondents mention and their mental health. In addition, regression analysis was used to explore simultaneously the relationship between the number of positive and negative mentions and wellbeing - thus providing a measure of the relative importance of the reporting of positive and negative influences. The analysis was repeated for those who have experience of mental health problems (both proxy and personal) and those who do not.

I.3 On the whole, the analysis revealed that neither the number nor the type of positive and negative influences mentioned by respondents were found to be correlated with their mental health rating as measured by the GHQ12 and WEMWBS.

2) Segmentation analysis of attitudes to mental health I.4 Segmentation analysis was undertaken on the attitudinal data to explore further the links between attitudes and socio-demographic and behavioural variables. The purpose of this analysis was to identify whether the nine attitudinal statements could be grouped into a smaller number of themes or ‘factors’ depending on the responses they elicit and, if so, to what extent respondents fell into distinct, like minded groups based on these factors. I.5 The analysis involved a two stage process. First, factor analysis was used to identify related statements. Factor analysis is a statistical data reduction tool that takes a set of data and simplifies it into a smaller number of underlying themes or ‘factors’ by grouping together questions that are answered in similar ways. The analysis produced a four factor solution as follows:

25 O’Connor et al, 2007. Predicting Short-term Outcome in Wellbeing Following Suicidal Behaviour: The Conjoint Effects of Social Perfectionism and Positive Future Thinking. Behaviour Research and Therapy, in press.

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Table I.1: Factor analysis 4 factor solution

Factor Composition 1 -People with mental health problems are often dangerous

-The public should be better protected from people with mental health problems -People are generally caring and sympathetic towards people with mental health problems

2 -Anyone can suffer from mental health problems -People with mental health problems should have the same rights as anyone else -People with mental health problems are largely to blame for their own condition

3 -If I were suffering from mental health problems I wouldn’t want people knowing about it -I would find it hard to talk to someone with mental health problems

4 -The majority of people with mental health problems recover I.6 Cluster analysis was used to identify to what extent respondents fell into like-minded groups on the basis of their attitudes in relation to each factor. A range of possible cluster solutions were identified, with the strongest of these comprising four clusters. None of the 4 clusters were particularly distinct, either in attitudinal or socio-demographic terms. However, the analysis did yield some interesting findings, several of which reinforced bivariate analyses presented in Chapter 7. Most notably it showed that:

• attitudes towards mental-ill health are characterised by a high levels of ambivalence with individuals tending to hold a mixture of positive and negative views.

• Men living in the most deprived areas of the country tend to hold the most negative attitudes overall

• People with a long term illness disability or infirmity are among those least likely to have concerns about disclosing a mental health problem to others – this may be because they are used to living with illness and to dealing with the attitudes of others towards their illness

• The most highly educated groups of respondents, tend to hold the most liberal attitudes towards people with a mental health problem but at the same time are the group most likely to agree that ‘If I were suffering from a mental health problem, I wouldn’t want people knowing about it’.

3) Relationship between ability to correctly diagnose the symptoms of specific mental health problems, and attitudes to mental health problems. I.7 An analysis was undertaken to explore whether respondents’ ability to correctly diagnose the symptoms described in the mental health scenarios varied in line with their attitudes to mental ill health, including their willingness to interact with people with mental health problems. For the purposes of this analysis, a new binary variable was created which reflected whether or not respondents correctly identified the mental health problem depicted in the scenario with which they were presented. This variable was then cross tabulated against responses to each of the attitudinal statements in the survey (QC1) and with the ‘willingness to interact’ statements from the scenarios section (QE5). In the event, there were no significant differences in the attitudes of those who were able to diagnose the symptoms correctly and those who were not.

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ANNEX J: MENTAL HEALTH SCENARIOS – QUESTION BY QUESTION ANALYSIS J.1 This annex presents a question by question analysis of findings from the mental health scenarios section of the questionnaire. J.2 Given that there were six scenarios, each was considered by a relatively small sub-sample of respondents. This point should be borne in mind when considering the aggregate level findings. To allow for sub-group analysis of findings pertaining to the scenarios, the data for the 2002, 2004 and 2006 surveys were combined thus tripling the sample size for each scenario (small sample sizes preclude such an analysis using only the 2006 data). Depression scenario Scenario text Male version Robert has been feeling really down for the last few weeks. He wakes up in the morning with a flat heavy feeling that stays with him all day long. He doesn’t enjoy things the way he normally would. In fact, nothing gives him pleasure. Even when good things happen, they don’t seem to make Robert happy. He has to force himself to get through the day, and even the smallest things seem hard to do. He finds it hard to concentrate on anything and has no energy at all. Even though Robert feels tired at night, he still can’t sleep, and wakes up too early in the morning. Robert feels worthless and feels like giving up. Robert’s family has noticed that he hasn’t been himself for about the last month. He doesn’t feel like talking and isn’t taking part in things like he used to. Female version Shona has been feeling really down for the last few weeks. She wakes up in the morning with a flat heavy feeling that stays with her all day long. She doesn’t enjoy things the way she normally would. In fact, nothing gives her pleasure. Even when good things happen, they don’t seem to make Shona happy. She has to force herself to get through the day, and even the smallest things seem hard to do. She finds it hard to concentrate on anything and has no energy at all. Even though Shona feels tired at night, she still can’t sleep, and wakes up too early in the morning. Shona feels worthless and feels like giving up. Shona’s family has noticed that she hasn’t been herself for about the last month. She doesn’t feel like talking and isn’t taking part in things like she used to. Causes of symptoms of depression J.3 Respondents were asked what they felt were the causes of the symptoms described in the depression scenarios. A majority of respondents, for both the male and female version of the scenario, thought the symptoms were likely to have been caused by stressful or disturbing events in Robert’s/Shona’s life, the circumstances in which he/she lives, physical illness or a chemical imbalance in the brain. The least commonly selected causes of the symptoms were the way Robert/Shona was brought up, fate or Robert’s/Shona’s own fault (table J.1 below).

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J.4 Respondents who were shown the female version of the depression scenario were less likely than those who were shown the male version to think the symptoms were due to Robert’s/Shona’s own fault or their personality. J.5 Comparing the findings with those from the previous surveys, the proportion saying that the symptoms may have been caused by Robert’s/Shona’s own personality was significantly higher in 2006 than in 2004 and 2002. Among those shown the female version of the scenario, the proportion saying the symptoms might have been caused by physical illness or the way Shona was brought up was significantly lower than that recorded in 2002 and 2004.

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Table J.1: Depression scenario. Likely causes of depression Q In your opinion, how likely or unlikely do you think it is that Robert’s/Shona’s condition might be caused by each of the following?

% Likely

Depression (Male) Depression (Female)

Base: All respondents presented with scenario

2002 %

2004 %

2006 %

2002 %

2004 %

2006 %


51 45 64 48 41 52

Chemical imbalance in the brain 64 66 67 69 69 62


45 37 39 36 44 33


93 92 88 92 93 87

Genetic or inherited problem 55 45 52 50 46 51


61 52 49 52 57 56

Fate 31 24 26 25 19 19

Physical illness 83 65 68 74 72 60

Robert’s/Shona’s own fault 21 21 19 14 13 9


n/a n/a 72 n/a n/a 73

Source: Ipsos MORI

J.6 Combining the datasets from all three waves of the survey allows analysis by subgroups of respondents. Age was found to be a significant variable: older age groups were more likely than younger age groups to attribute the symptoms of depression to Robert/Shona’s own character or personality (male version: 71% of those aged 75+ compared with 41% of those aged 16-24), Robert’s/Shona’s upbringing (female version: 51% of those aged 65-74 compared with 31% of those aged 45-54) and fate (male version: 38% of those aged 75+ compared with 19% of those aged 35-44 years). Younger age groups were more likely to think the symptoms were due to a chemical imbalance in the brain (female version: 82% of those aged 25-34 compared with 50% of those aged 75+) or physical illness (female version 78% of those aged 45-54 compared with 61% of those aged 65-74). J.7 In terms of level of household income, those whose income was over £36,400 per annum were least likely to attribute symptoms to Robert’s/Shona’s upbringing (male version: 30% of those with a household income of more than £36,400 compared with 49% of those with between £15,600 and £26,000), a chemical imbalance in the brain (female version: 9% versus 23% of those with a household income of under £5,200) or fate (female version: 10% versus 29% of those with a household income of between £5,200 and £15,600).

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Support mechanisms for the person in the depression scenario J.8 When asked to consider the most appropriate sources of help for the person in the depression scenario, the majority of respondents mentioned a family doctor or a family member. As illustrated in table J.2, the next most common responses were a qualified counsellor, a psychiatrist, a friend or a neighbour or a psychologist. There was little variation in the results depending on which version of the scenario respondents had been asked to consider. J.9 However, version differences are apparent when the data from the three surveys are compared. Among those shown the male version of the scenario, the proportion who felt that the best person to help Robert would be someone with the same problem has fallen between 2004 and 2006. Among those shown the female version, the proportion suggesting a friend or neighbour or a voluntary organisation or charity has also fallen (table J.2).

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Table J.2: Depression scenario. Support for Robert/Shona Q Say it was possible for any of the people on this card to help Robert/Shona. Who would be the three best people to do this?



2002 %

2004 %

2006 %

2002 %

2004 %

2006 %

A family doctor 66 71 72 56 65 64

Someone in the family 42 53 56 38 52 48

A qualified counsellor 59 51 44 58 47 52

A psychiatrist 29 26 29 33 26 21

Someone with the same problem

33 25 17 34 21 23

A friend or neighbour 23 17 18 28 36 24

A psychologist 15 17 18 20 15 21


7 11 14 11 16 9

A social worker 9 7 4 5 6 7

A nurse 3 3 1 3 4 5

A home help/carer 3 2 * 4 4 3

Someone else 1 2 1 - 2 3

No one - - - - - -

None of these - * - - - -

Don’t know - 1 * 1 1 1

Source: Ipsos MORI

J.10 Younger respondents were more likely than older respondents to think a friend or neighbour would be the best person to help (male version: 30% of those aged 16-24 versus 13% of those aged 65-74). There were few other differences. Where the person described in the depression scenario should live J.11 As illustrated in table J.3, the overwhelming majority felt that the best place for the person in the depression scenarios to live would be in their own (or their family’s) home. This is consistent with the result from the 2004 survey.

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Table J.3: Depression scenario. Suitable place for Robert/Shona to live26 Q If all of these options on this card were possible, where do you think it would be best for Robert/Shona to live?

Depression (Male)

Depression (Female)

Base: All respondents presented with scenario 2004 %

2006 %

2004 %

2006 %

In their own home (or family’s) home 80 78 81 75

In special housing with professional support in the community

14 15 13 13

In a residential or nursing home 1 1 1 3

In hospital 2 2 3 4

Don’t know 3 4 2 5

Source: Ipsos MORI Depression scenario: possibility of harm/violence J.12 Around half of respondents shown the depression scenario thought that Robert/Shona might do something harmful or violent to themselves. There was little difference depending on whether the respondent had been shown the male or female version of the scenario, by sub-group of respondent and also little change between the 2004 and 2006 surveys (table J.4). Table J.4: Depression scenario. Likelihood of doing something harmful/violent to him/herself

Q In your opinion, how likely is it that Robert/Shona would do something harmful or violent to him/herself?



2002 %

2004 %

2006 %

2002 %

2004 %

2006 %

Very likely 10 5 9 11 10 8

Somewhat likely 41 42 39 44 39 42

Somewhat unlikely 32 36 28 24 29 29

Very unlikely 11 11 14 18 17 15

Don’t know 6 6 9 4 5 7

Source: Ipsos MORI

J.13 A minority of respondents who considered the depression scenario felt that Robert/Shona might do something harmful or violent to others. This figure has increased between 2004 and 2006, 26 In 2002 different response codes were used for this question meaning the results are not directly comparable. Thus they are excluded from this table and no sub-group analysis was conducted for this question.

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following a decline over the first two waves of the survey (table J.5 below). While this is a disappointing result, it is consistent with an increase in the proportion of people agreeing the public should be better protected, discussed in the previous chapter. Table J.5: Depression scenario. Likelihood of doing something harmful/violent to others

Q In your opinion, how likely is it that Robert/Shona would do something harmful or violent to others?



2002 %

2004 %

2006 %

2002 %

2004 %

2006 %

Very likely * 1 2 1 3 1



Very unlikely 33 40 40 46 48 48

Don’t know 5 7 10 3 4 5

Source: Ipsos MORI

Social interaction with the person in the depression scenario J.14 Respondents were asked how willing they would be to interact with Robert/Shona under a number of different circumstances, from doing them a favour, to working with them or having them provide childcare for someone in their family. J.15 As illustrated in table J.6, majorities would be willing to do Robert/Shona a favour, make friends with them, spend an evening socialising with them, make friends with them and start working closely with them. Respondents shown the female version were generally more sympathetic towards the person with symptoms of depression; they were more likely than those shown the male version to spend an evening socialising with Robert/Shona, make friends with them, start working closely with them, have them marry into the family and do them a favour. J.16 Between 2004 and 2006, there have been some notable decreases in the proportions of respondents willing to interact with Robert/Shona. Specifically, the proportion of respondents willing to start working closely with Robert/Shona or have them marry into the family has dropped significantly between 2004 and 2006 for both the male and female scenarios. Among those shown the male scenarios, the proportions willing to move next door to Robert, spend an evening socialising with him, make friends with him and have him provide childcare have also decreased. These changes are somewhat surprising given the consistency of attitudes towards mental health between 2004 and 2006 described elsewhere throughout this report. Possible explanations for the changes are discussed in chapter 8.

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Table J.6: Depression scenario. Social interaction with Robert/Shona Q How willing would you be to…?

% Willing



2002 %

2004 %

2006 %

2002 %

2004 %

2006 %


62 79 65 74 75 70


67 75 60 68 81 79


75 82 71 74 86 82


61 73 54 54 80 70

Have Robert Shona marry into the family

32 49 34 46 57 47


88 90 88 88 92 94

Have Robert/Shona provide childcare for someone in your family (e.g. babysitting, childminding)

n/a 23 15 n/a 28 21

Source: Ipsos MORI

J.17 Women were generally more willing than men to interact with the people described in the depression scenario. In particular, women were more likely to be willing to make friends with Robert/Shona (male version: 81% versus 68%) and to start working closely with them (female version: 82% versus 64%). Among those shown the female version of the scenario, women were more likely than men to be willing to move next door to Shona (77% versus 69% to spend an evening socialising with her (84% versus 68%) and have her marry into the family (55% versus 44%) J.18 Younger people were more likely than older people to be willing to move next door to Robert/Shona (male version: 73% of 35-44 year olds compared with 54% of 65-74 year olds), to spend an evening socialising with them (female version: 84% of 25-34 year olds compared with 62% of 75+ year olds), to make friends with them (male version: 78% of 35-44 year olds compared with 60% of 65-74 year olds), to start working with them (female version: 81% of 25-34 year olds compared with 56% of 75+ year olds), or have Robert/Shona marry into the family (male version: 47% of 25-34 year olds compared with 14% of 65-74 year olds). J.19 There were also differences by experiences of mental health. Those who had personal experience of a problem were more likely than those who did not to be willing to move next door to Robert/Shona (female version: 80% versus 67%), to spend an evening socialising with them (male version: 74% versus 49%), to start working closely with them (female version: 81% versus 68%), to have them marry into the family (male version: 49% versus 22%) or to do them a favour (female

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version: 94% versus 87%). And, among those shown the male version of the scenario those with personal experience of a mental health problem were more likely than those who did not have any personal experience to make friends with Robert (84% versus 59%). In general, people with proxy experience of mental health were also more likely than those with no contact to be willing to interact with Robert/Shona in most of these circumstances. Freedoms and rights of person with depression J.20 Respondents were asked if they thought that Robert’s/Shona’s freedoms and rights might have to be limited because of their illness. Over a third felt this was likely (37% of those shown the male version and 35% of those shown the female version), while around a half thought it was unlikely (53% of those shown the male version and 57% of those shown the female version). Diagnosis of depression J.21 Respondents were asked to pick from a list of 15 options the most likely diagnosis of the symptoms described. A majority of those shown the depression scenarios were able to fit the symptoms to the condition correctly, though the figure was higher among those shown the female version than among those shown the male version (table J.7 below). The results are consistent with those for 2004.

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Table J.7: Depression scenario. Diagnosis Q The description I read out for Robert/Shona was designed with one particular mental health problem in mind. Which one of these do you think it is most likely to be?



2004 %

2006 %

2004 %

2006 %

Alzheimer’s Disease/dementia - - - 1

Anxiety Disorder 6 3 2 5

Depression 69 69 75 75


- - - 1


5 5 4 3

Nervous breakdown 6 6 7 5


- 1 - *

Panic attacks 1 - * *

Personality disorder 5 2 2 1

Phobias (e.g. Agoraphobia) - * * -

Post-natal depression - - 2 2

Post-traumatic stress disorder n/a 1 n/a *

Schizophrenia 1 1 1 1

Self harm - - * *

Severe stress 5 3 3 4

Other * * 1 *


Source: Ipsos MORI

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Schizophrenia scenario Scenario text Schizophrenia (male) Robert is a man who was doing pretty well until about a year ago. But then things started to change. He thought that people around him were criticising him and talking behind his back. Robert was convinced that people were spying on him and that they could hear what he was thinking. Robert couldn’t work any more, and he stopped joining in with family activities. He retreated from everything, until he eventually spent most of his day in his room. Robert heard voices even though no one else was around. These voices told him what to do and what to think. He has been living this way for six months. Schizophrenia (female) Shona is a woman who was doing pretty well until about a year ago. But then things started to change. She thought that people around her were criticising her and talking behind her back. Shona was convinced that people were spying on her and that they could hear what she was thinking. Shona couldn’t work any more, and she stopped joining in with family activities. She retreated from everything, until she eventually spent most of her day in her room. Shona heard voices even though no one else was around. These voices told her what to do and what to think. She has been living this way for six months. Causes of the symptoms of schizophrenia J.22 As illustrated in table J.8, the most likely cause of the symptoms described in the schizophrenia scenario was felt to be stressful or disturbing events in Robert’s/Shona’s life. Large majorities also mentioned a chemical imbalance in the brain and the circumstances in which Robert/Shona lives. Respondents shown the male version were more likely than those shown the female version to cite Robert’s/Shona’s own character or personality as a cause. J.23 In general, the 2006 results are consistent with those for 2004. However, among those shown the male version of the scenario, the proportion who felt the symptoms could be caused by Robert’s own character or personality has risen by almost 25 percentage points. Like other changes in attitudes observed throughout this section, this increase could also be accounted for, in part, by the media representation of mental health problems - among men. For example, some of the negative media coverage characterised people with mental health problems as being male, dangerous and having problems which were intractable, in other words characteristics of the individual (i.e., character or personality).

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Table J.8: Schizophrenia scenario. Likely causes of schizophrenia Q In your opinion, how likely or unlikely do you think it is that Robert’s/Shona’s condition might be caused by each of the following?

% Likely

Schizophrenia (Male) Schizophrenia (Female)


2002 %

2004 %

2006 %

2002 %

2004 %

2006 %


56 51 75 60 50 52



49 48 45 41 38 42


90 90 91 89 94 91



59 63 59 61 64 59

Fate 26 24 27 24 23 18




n/a n/a 78 n/a n/a 65

Source: Ipsos MORI

J.24 Older people were more likely than younger groups to think that the symptoms could be attributed to Robert’s/Shona’s own character or personality (male version: 71% of people aged 75 and over compared with 51% of those aged 35 to 44 years) or fate (male version: 34% of people aged 75 and over, compared with 18% of people aged 35 to 44 years). J.25 There were also differences by experience of mental ill-health. Those with personal or proxy experience were less likely than those with no experience to think that the symptoms could be caused by Robert or Shona’s own character or personality (male version: 61% and 58% versus 72% respectively), or Robert/Shona’s own fault (male version: 8% and 10% versus 30%), and more likely to think the symptoms were caused by a chemical imbalance in the brain (male version: 76% and 79% versus 69%), or a genetic or inherited problem (male version: 64% and 65% versus 52%). Additionally, among those shown the female version of the scenario, people with personal or proxy experience were also more likely to think the symptoms could be caused by stressful or disturbing events (93% and 94% versus 83%) and less likely to think they were caused by fate (73% and 76% thought this was unlikely, compared with 60%).

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Support mechanisms for the person in the schizophrenia scenario J.26 When asked who the best person to help Robert/Shona would be, around half mentioned a family doctor, a psychiatrist and a qualified counsellor. Those asked to consider the female scenario were more likely than those shown the male scenario to think a friend or neighbour would be the best person to help, while those shown the male version were more likely to mention someone in his family. J.27 Among those shown the male version, the proportion who thought someone in the family would be the best person to help has risen between 2004 and 2006. Meanwhile, among those shown the female version, the proportion who said a friend or neighbour would be the best help has risen and the proportion who thought someone with the same problem could help has fallen.

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Table J.9: Schizophrenia scenario. Support for Robert/Shona Q Say it was possible for any of the people on this card to help Robert/Shona. Who would be the three best people to do this?



2002 %

2004 %

2006 %

2002 %

2004 %

2006 %



A nurse 4 3 5 5 5 2

A home help/carer 9 3 3 6 2 2



A family doctor 55 60 56 55 55 55




4 12 8 8 11 10

Someone with the same problem

21 18 19 28 25 16

Someone else 1 3 * 2 1 *

No one * - - * - -

None of these - - - - - -

Don’t know * 2 * 1 1 1

Source: Ipsos MORI

J.28 Men were more likely than women to suggest that someone in the family would be the best person to help (male version: 52% versus 40%) while women were more likely to suggest a qualified counsellor (male version: 57% versus 41%). This may reflect the fact that women are more likely to seek professional help in response to health concerns (e.g., Galdas et al., 2005). There was also some variation by age, with younger groups being more likely than older people to suggest someone in the family (male version: 62% of people aged 16 to 24 years, compared with 38% of people aged 60 to 64 years). Where the person described in the schizophrenia scenario should live J.29 As in 2004, around three in five respondents felt that Robert/Shona should live in their own home, while most of the remaining respondents felt they should live in special housing with professional support in the community. The results are consistent for both the male and female versions of the scenarios.

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Table J.10: Schizophrenia scenario. Suitable place for Robert/Shona to live Q If all of these options on this card were possible, where do you think it would be best for Robert/Shona to live?

Schizophrenia (Male)

Schizophrenia (Female)


2004 %

2006 %

2004 %

2006 %

In their own home (or family’s) home 58 54 61 58


30 33 31 30

In a residential or nursing home 4 3 4 2

In hospital 3 5 3 5


Source: Ipsos MORI Schizophrenia scenario: possibility of harm violence J.30 Consistent with 2004 results, around seven in ten felt that Robert/Shona was likely to do something harmful or violent to him/herself. Table J.11: Schizophrenia scenario. Likelihood of doing something harmful/violent to him/herself

Q In your opinion, how likely is it that Robert/Shona would do something harmful or violent to him/herself?



2002 %

2004 %

2006 %

2002 %

2004 %

2006 %

Very likely 10 11 12 18 11 12



Very unlikely 12 5 8 8 4 10

Don’t know 3 8 12 5 3 12

Source: Ipsos MORI

J.31 Among those shown the male version, younger people were more likely than older groups to think that Robert would harm himself (81% of people aged 16 to 24 year versus, for example, 52% of people aged 55 to 59 years). There were few other notable sub-group differences for this item.

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J.32 Around a third felt that Robert/Shona was likely to harm others. While the figures for the male scenario were consistent with those for 2004, the proportion suggesting that Shona was likely to harm others has fallen by 10 percentage points. Table J.12: Schizophrenia scenario. Likelihood of doing something harmful/violent to others

Q In your opinion, how likely is it that Robert/Shona would do something harmful or violent to other people?



2002 %

2004 %

2006 %

2002 %

2004 %

2006 %

Very likely 4 5 4 5 5 5



Very unlikely 21 20 22 21 22 27

Don’t know 4 6 13 6 4 15

Source: Ipsos MORI

J.33 Again, younger people who were shown the male version of the scenario proved more likely than people in older groups to think that Robert would harm others (59% of those aged 16 to 24 years versus, for example, 23% of people aged 55 to 59 years). J.34 Among those shown the female version, people with personal or proxy experience of mental ill-health were less likely than those with no experience to say that Shona would do something harmful to others (66% and 68% thought this unlikely compared with 50% of those with no experience), although in part this reflects the fact that those with no experience were more likely to give a ‘don’t know’ response. Social interaction with the person in the schizophrenia scenario J.35 In terms of willingness to interact with the person described in the schizophrenia scenario, the majority of respondents said they would be willing to move next door to Robert/Shona, spend an evening socialising with them, make friends with them, start working closely with them and do them a favour. However, only around one in ten were willing to have Robert/Shona provide childcare for someone in their family. J.36 Respondents shown the female version of the scenario were generally less wary of the person in the schizophrenia scenario than those shown the male version. Thus more respondents considering the female scenario said they would spend an evening socialising with Shona, start working closely with Shona and have Shona marry into the family. J.37 As with the depression scenarios, respondents were generally less willing to interact with the person in the schizophrenia scenario than in 2004. Specifically, the proportion of respondents shown either version of the scenario who said they would make friends with Robert/Shona has fallen. Similarly, those considering the male scenario in 2006 were less likely than in 2004 to say they would work with Robert, and those considering the female scenario were significantly less

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likely in 2006 to say they would move next door to Shona, do her a favour or have her look after their children. Table J.13: Schizophrenia scenario. Social interaction with Robert/Shona

Q How willing would you be to…?

% Willing

Schizophrenia (Male) Schizophrenia(Female)


2002 %

2004 %

2006 %

2002 %

2004 %

2006 %


62 58 58 68 74 61


68 65 57 75 74 68


66 76 64 81 80 72


63 63 50 65 72 66


28 27 26 42 44 36


91 88 84 94 94 85


n/a 10 10 n/a 23 15

Source: Ipsos MORI

J.38 Among those shown the female version, women were more willing to make friends with Shona (82% versus 74%), and those with personal or proxy experience of mental ill-health were more willing than those with no experience to have Shona marry into the family (52% and 43% versus 36%). J.39 For both versions, older respondents were less willing than younger groups to work closely with Robert/Shona (female version: 30% of people aged 75 and over were unwilling versus 10% of people aged 25 to 34 years), or have them provide childcare (female version: 69% of people aged 75 and over were unwilling, versus 32% of people aged 16 to 24 year). Among those shown the male version, older groups were also less willing to have Robert marry into the family (64% of people aged 75 and over were unwilling, compared with 20% of people aged 16 to 24 years). J.40 People with personal or proxy experience of mental ill-health were more willing than those with no experience to start working closely with Robert/Shona (female version: 31% and 23% were very willing versus 12%). And, among those shown the female version, people with personal or proxy experience were more willing to spend an evening socialising with Shona (80% and 76% versus 64%).

171

Freedoms and rights of person with schizophrenia J.41 Around half of respondents shown either the female or male version of the schizophrenia scenario felt that it was likely that Robert’s/Shona’s freedoms and rights might have to be limited because of their symptoms (50% of those shown the male scenario and 52% of those shown the female one). Diagnosis of schizophrenia J.42 Around two in five of those shown the female version of the schizophrenia scenario and 35% of those shown the male version correctly attributed the symptoms described. A range of other diagnoses were suggested by the remaining respondents. Around one in five in each case thought that Robert/Shona could be suffering from depression while one in ten suggested they were suffering from a nervous breakdown (table J.14 below). J.43 The results are broadly comparable with 2004; the only difference is that among those shown the male version of the scenario, where the proportion who thought Robert was suffering from depression has risen.

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Table J.14: Schizophrenia scenario. Diagnosis Q The description I read out for Shona/Robert was designed with one particular mental health problem in mind. Which one of these do you think it is most likely to be?

Schizophrenia (Male)

Schizophrenia (Female)


2004

%

2006

%

2004

%

2006

%

Alzheimer’s Disease/dementia 1 1 * 1



Eating disorder (anorexia, bulimia) - * - 1


6 4 4 8



2 2 3 1

Panic attacks 3 1 1 2


Phobias (e.g. Agoraphobia) 1 1 3 1

Post-natal depression - * 1 1

Post traumatic stress disorder n/a * n/a 2

Schizophrenia 44 35 36 39

Self harm - 1 - 1


Other 1 4 - 1


Source: Ipsos MORI J.44 People with personal or proxy experience of mental ill-health were more likely than those with no experience to correctly diagnose schizophrenia (male version: 33% and 28% versus 18%). Among those shown the male version, women were more likely to give the correct diagnosis than men (31% versus 21%). There was no gender differences among those shown the female version.

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Stress scenario Scenario text Male version Robert is a man who was doing pretty well until about a year ago. While nothing much was going wrong in Robert’s life, he had a few problems that were really beginning to get to him. He started to feel worried, and a little sad, and had trouble sleeping at night. Things bothered him more than they bothered other people, and he started to get nervous and annoyed when things went wrong. Otherwise Robert is doing OK. He enjoys being with other people, and though he sometimes argues with his family, he has generally been getting on pretty well with them. Female version Shona is a woman who was doing pretty well until about a year ago. While nothing much was going wrong in Shona’s life, she had a few problems that were really beginning to get to her. She started to feel worried, and a little sad, and had trouble sleeping at night. Things bothered her more than they bothered other people, and she started to get nervous and annoyed when things went wrong. Otherwise Shona is doing OK. She enjoys being with other people, and though she sometimes argues with her family, she has generally been getting on pretty well with them. Causes of symptoms of stress J.45 As in 2004, respondents felt that the most likely cause of the symptoms depicted in the stress scenario was stressful or disturbing events in Robert’s/Shona’s life. The next most commonly suggested causes were the circumstances in which Robert/Shona lives, followed by Robert’s/Shona’s own character or personality and physical illness. Respondents shown the female version of the scenario were more likely than those shown the male version to associate the symptoms with the way Robert/Shona was brought up. J.46 Between 2004 and 2006 there has been an increase in the proportion of respondents who said the symptoms may have been caused by Robert’s/Shona’s own character or personality. Among those shown the female version of the scenario, there has also been an increase in the proportion identifying the way Shona was brought up, while the proportions mentioning fate and physical illness have decreased.

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Table J.15: Stress scenario. Likely causes of stress Q In your opinion, how likely or unlikely do you think it is that Robert’s/Shona’s condition might be caused by each of the following?

% Likely

Stress (Male) Stress (Female)


2002 %

2004 %

2006 %

2002 %

2004 %

2006 %


69 56 67 71 56 68



48 45 42 46 39 52


90 88 87 85 84 89



52 50 47 46 44 49

Fate 28 30 28 29 37 27




n/a n/a 73 n/a n/a 76

Source: Ipsos MORI

J.47 Among those shown the female version of the scenario, men were more likely than women to think the symptoms were due to a genetic or inherited problem (50% versus 40%) or physical illness (39% versus 27%). J.48 There was also variation by age among those shown the male version of the scenario: those in the oldest age group were the most likely to think the symptoms of stress were caused by a chemical imbalance in the brain (20% compared with 68% of those aged 16-24) while those in the youngest age group were among the most likely to think the symptoms were due to fate (77% compared with 55% of those aged over 75 years). J.49 Among those shown the male version of the scenario, those with personal or proxy experience of mental ill-health were more likely than those with no experience to attribute the symptoms to a chemical imbalance in the brain (61% of those with personal experience and 59% of those with proxy experience versus 43% of those with no experience) while among those shown the female scenario, those with no experience were more likely than those with personal experience to feel the symptoms were Shona’s own fault.

175

Support mechanisms for the person in the stress scenario J.50 The best person to help Robert/Shona was thought to be a doctor, although this was closely followed by someone in the family. Around two in five also mentioned a qualified counsellor or a friend or neighbour. Those shown the female version of the scenario were more likely than those shown the male version to mention friends or neighbours as sources of support, while those shown the male version were more likely to mention family members. The results are consistent with those for 2004 (table J.16 below).

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Table J.16: Stress scenario. Support for Robert/Shona Q Say it was possible for any of the people on this card to help Robert/Shona. Who would be the three best people to do this?



2002 %

2004 %

2006 %

2002 %

2004 %

2006 %



A nurse 2 3 1 4 2 4

A home help/carer 5 4 2 6 3 3



A family doctor 63 64 62 66 58 61




6 5 9 12 8 8

Someone with the same problem 37 29 23 28 31 24

Someone else 2 1 1 * 1 2

No one * * - - 1 -

None of these - - - - - -

Don’t know - 1 1 - 1 1

Source: Ipsos MORI

J.51 Among those shown the female scenario, those who had personal experience of a mental health problem were more likely than those with no experience to think a family doctor would be the best person to help (72% versus 58%). There was little other sub-group variation. Where the person described in the stress scenario should live J.52 In line with the 2004 findings, a majority of respondents thought the best place for Robert/Shona to live would be in their own home and around one in ten felt they should live in special housing with professional support in the community.

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Table J.17: Stress. Suitable place for Robert/Shona to live Q If all of these options on this card were possible, where do you think it would be best for Robert/Shona to live?



2004 %

2006 %

2004 %

2006 %

In their own (or family’s) home 84 83 82 81


10 12 14 12

In a residential or nursing home 1 - 1 3

In hospital 1 * - 1

Other 2 3 - *


Source: Ipsos MORI Stress scenario: possibility of harm/violence J.53 Around one in five respondents thought it likely Robert/Shona would do something harmful or violent to him/herself but the figure was lower among those shown the female version of the scenario. These findings are broadly consistent with those reported in 2004.

Table J.18: Stress scenario. Likelihood of doing something harmful/violent to him/herself

Q In your opinion, how likely is it that Robert/Shona would do something harmful or violent to him/herself? Stress (Male) Stress (Female)


2002 %

2004 %

2006 %

2002 %

2004 %

2006 %

Very likely 3 2 5 6 1 1



Very unlikely 30 26 26 33 27 39

Don’t know 2 7 9 6 7 6

Source: Ipsos MORI

J.54 A minority of respondents shown the stress scenario felt that Robert/Shona would be likely to do something harmful or violent to others. This is consistent with 2004.

178

Table J.19: Stress scenario. Likelihood of doing something harmful/violent to others

Q In your opinion, how likely is it that Robert/Shona would do something harmful or violent to others?



2002 %

2004 %

2006 %

2002 %

2004 %

2006 %

Very likely 2 1 3 1 * 1



Very unlikely 43 38 44 51 42 52

Don’t know 2 6 8 6 6 6

Source: Ipsos MORI

Social interaction with the person in the stress scenario J.55 In terms of respondents’ willingness to interact with the person in the stress scenario, the results are in some respects consistent with those for 2004. Thus large majorities were willing to do Robert/Shona a favour, make friends with them, spend an evening socialising with them or move next door to them. However, there were also some notable differences in the two sets of results. Among those shown the male version of the scenario, the proportions willing to move next to Robert or to do him a favour has fallen. And, among those shown the female version of the scenario, the proportion willing to make friends with Shona has decreased. J.56 As was the case for both depression and schizophrenia, respondents were generally more willing to interact with a female showing symptoms of stress than with a male showing the same symptoms. This was particularly the case with respect to having him marry into the family or doing him a favour.

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Table J.20: Stress scenario. Social interaction with Robert/Shona Q How willing would you be to…?

% Willing



2002 %

2004 %

2006 %

2002 %

2004 %

2006 %


82 79 67 77 82 75


79 79 75 87 84 78


87 86 81 92 88 80


82 78 67 74 80 71


54 52 47 56 67 53


95 94 85 97 95 93


n/a 33 26 n/a 41 34

Source: Ipsos MORI

J.57 Among those shown the male version of the scenario, women were more likely than men to be willing to move next door to Robert (81% versus 71%) while among those shown the female version of the scenario, women were more likely than men to be willing to spend an evening socialising with Shona (87% versus 80%). J.58 Younger respondents were more likely than older respondents to be willing to have Robert/Shona marry into the family (male version:73% of those aged 25-34 compared with 24% of those aged 65-74). J.59 Among those shown the male version of the scenario, those with personal or proxy experience of a mental health problem were more likely than those with no personal experience to be willing to move next door to Robert (79% and 79% versus 67%), make friends with Robert (89% and 87% versus 75%), start working closely with Robert (78% and 80% versus 63%). Freedoms and rights of person with stress J.60 When asked if the person described in the stress scenario might have to have their freedoms and rights limited, around one in five thought this likely (18% of those shown the male scenario and 25% of those shown the female scenario). This was lower than the proportions recorded among those shown the depression and schizophrenia scenarios which may reflect the less serious nature of the stress-related symptoms.

180

Diagnosis of stress J.61 Consistent with the findings from 2004, around one in ten attributed the symptoms described in the scenario to severe stress. However, almost half thought Robert/Shona was exhibiting symptoms of depression and around one in five thought he/she was experiencing an anxiety disorder. Table J.21: Stress scenario. Diagnosis

Q The description I read out for Shona/Robert was designed with one particular mental health problem in mind. Which one of these do you think it is most likely to be?


Base: All respondents presented with scenario % % % %

Alzheimer’s Disease/dementia 1 - * -



Eating disorder (anorexia, bulimia) - * * -

Manic depression (bipolar affective disorder) * 2 2 2


Obsessive/compulsive behaviour/disorder * - - -

Panic attacks 2 1 1 3


Phobias (e.g. Agoraphobia) - - - *

Post-natal depression - * 1 -

Post-traumatic stress disorder n/a * n/a 1

Schizophrenia 1 - 1 1

Self harm - 2 * -


Other * 3 - 1


Source: Ipsos MORI

Well? What Do You Think?(2006)

The Third National Scottish Survey ofPublic Attitudes to Mental Health, MentalWell-being and Mental Health Problems

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