6.1 The mental health and wellbeing of populations, and in particular adopting policies and practices which reduce stigma and discrimination for those experiencing mental health problems of all kinds, has been a focus of policy making both in Scotland and internationally since the early 2000s. Based on our analysis of SSA 2013 and the earlier Well? surveys, this final chapter sets out our main conclusions in relation to how attitudes to people with mental health problems have changed over the last decade, what factors are related to public attitudes towards people with mental health problems, and what the experiences of those with mental health problems have been.
6.2 Post-devolution Scottish policy in this area has emphasised human rights, improving recovery, reducing inequality, and promoting social justice. This approach has incorporated policy and practice initiatives to reduce both stigmatising attitudes and discriminatory behaviours (that is behaviour by individuals and institutions that either deliberately or inadvertently excludes people with mental health problems from enjoying the rights, dignity, services, social relationships, and resources available to others). Reducing the prevalence of stigmatising attitudes is important in its own right and helps to build good relations between all sections of society. Moreover, since attitudes often underpin behaviour, reducing stigmatising attitudes might also be expected to reduce discriminatory behaviour in the longer term.
6.3 The analysis in this report uses data from SSA 2013 together with data from previous Well? surveys conducted between 2002 and 2008. Together these surveys cover a period (2002-2013) which includes the relatively strong economic phase preceding the start of the downturn in 2007 and the years of economic austerity, uncertainty and public sector budget constraint which have followed.
6.4 It might be expected that the recession would have an impact on the prevalence of mental health problems. However, the evidence which would be needed to explore this is far from conclusive. The most recent overview (based on a wide range of sources) of Scotland-specific data for mental health and wellbeing, together with trends over time, presents a fairly mixed picture (NHS Health Scotland, 2012). The detailed analysis of time trends show, for example, that rates of suicide have improved, that there has been no significant change in the incidence of common mental health problems, and that levels of possible alcohol dependency have increased. Moreover, time trend data are not (yet) available for some key indicators (mental wellbeing, depression, anxiety and deliberate self-harm) leaving, according to the report, 'a fair amount of uncertainty regarding how adult mental health has changed over recent years'.
6.5 SSA 2013 and the previous Well? surveys showed that the proportion with personal experience of mental health problems has remained fairly stable since 2002 at around one-quarter, as has the proportion who said they knew someone with any kind of mental health problem (around two-thirds). Women, those in the lowest income group, and those under 55 were more likely to say they had had personal experience of a mental health problem. The condition with which respondents were most familiar was depression; over one half of all respondents (51%) said they knew someone with depression. Despite the overall stability in the proportion who knew someone with a mental health problem, there has been an increase of between 6% and 10% since 2008 in those saying they knew someone with depression, dementia or an anxiety disorder.
6.6 Overall, the evidence from this report indicates that public attitudes towards mental health and those with mental health problems have been fairly stable in Scotland over the last decade, with no clear trend towards either a reduction or an increase in stigmatising attitudes being detected. However, there have also been a few important changes relating to specific questions (see below) which cannot be fully explained by the survey data alone. Moreover, it is not possible to say, on the basis of this analysis, whether the patterns which have been observed would have been different had the economy not gone into recession in 2008.
6.7 In some areas this stability provides evidence of continued widespread acceptance and tolerance of people with mental health problems by the general public. For example, there is almost universal acceptance of the possibility of 'anyone' experiencing a mental health problem (between 93% and 98% believed so on all five occasions that the question was asked between 2002 and 2013) and almost universal disagreement that people experiencing mental health problems are 'largely to blame' for their condition (93%-96% disagreed on all five occasions).
6.8 However, alongside these tolerant attitudes, responses also indicated that the public hold a range of stigmatising attitudes, none of which has decreased over time. In particular: almost half of respondents (between 41% and 50% in each of the five surveys) would not want people to know if they experienced a mental health problem; about 1 in 5 (between 15% and 20%) would find it hard to talk to someone with mental health problems; between one-quarter and one-third (25% to 35%) thought the public should be better protected from people with mental health problems; and the proportion who thought people with mental health problems are dangerous remained consistent (between 15% and 19% in the period 2004-2013, although a higher figure was recorded in 2002).
6.9 Contrasted with this fairly stable picture are two attitudes that have shown some change over time, although in neither case is there an obvious explanation. First, the proportion who thought 'people with mental health problems should have the same rights as anyone else' was lower in 2013 (82%) than when it was first recorded in 2002 (88%) and slightly lower than the 2008 figure (86%).
6.10 Second, the proportion of people who agreed that 'the majority of people with mental health problems recover' has shown a clear downward trend over time from 50% in 2002 to 33% in 2013. This latter finding may simply be an artefact of different interpretations of the terminology employed. It is unclear whether respondents interpret mental health recovery as living symptom-free or living well and managing ongoing symptoms. Greater public debate and more visible discussion of mental health may also have affected the conceptualisation of 'recovery' which respondents are applying. It is notable that those with personal experience of mental health problems were more likely than those without to agree that 'the majority of people with mental health problems recover' (44% of those with personal experience compared to 30% of those without).
6.11 In relation to public attitudes towards people showing the symptoms of depression and schizophrenia, in 2013 there was evidence that a sizeable minority (15% in the case of someone with depression and 22% in the case of someone with schizophrenia) were unwilling to have any form of social interaction with these individuals. This would appear to indicate that at least 1 in 7 hold distinctly stigmatising attitudes towards people displaying symptoms of schizophrenia or depression. A smaller, but still not insignificant proportion (9% in the case of depression and 14% in the case of schizophrenia), were unwilling to have this person as a work colleague.
6.12 However, large numbers of the general population displayed inclusive attitudes towards people displaying symptoms of schizophrenia and depression. More than three-quarters (76%) would be willing to make friends with someone with depression and two-thirds (66%) with someone with schizophrenia. Moreover, almost one-half (45%) were willing for someone with depression to marry into the family, and one-third (34%) for someone with schizophrenia.
6.13 Views on whether someone with schizophrenia or depression might do something harmful to others varied considerably according to the condition being considered. Almost half (43%) believed this was possible in the case of schizophrenia compared with just 1 in 10 for depression. Given the low likelihood that someone with a mental health problem will harm others, this overestimate of the risk by the general public indicates a need for education and awareness-raising to foster better public understanding.
6.14 The evidence specifically in relation to those who have personal experience of mental health problems is mixed, with some aspects remaining stable over time and some showing marked changes. The changes which were found are not easy to interpret or explain (see below) and further research would be required to elucidate the factors which underlie them.
6.15 Three main features have remained fairly stable over time for those with personal experience of mental health problems. First, the extent to which they would tell others about their mental health problems has not changed. In 2013, 85% said they had told 'someone', 19% said they had told their manager or boss at work, and 17% said they had told other colleagues at work. These figures are similar to those recorded in 2006 and 2008. The figures for those who would be comfortable telling their boss suggest that there is more work to be done in creating supportive and stigma-free workplaces.
6.16 Second, the factors which people identified as hindering their recovery have been stable over time. The five factors chosen most frequently in 2013 were: 'not acknowledging I had a problem' (18%); 'not understanding what was going on' (16%); not feeling able to tell people' (15%); 'continuing to experience symptoms' (13%); and 'negative attitudes of those around me' (11%). Note that this last factor is a direct indicator of the extent of stigmatising attitudes which those with mental health problems encounter. These factors highlight a range of potential policy and practice considerations for the future.
6.17 Third, the social impacts reported by those who had personal experience of mental health problems increased between 2008 and 2013 but were at a similar level to those found in 2004. In 2004, 36% reported a social impact of any kind compared with 23% in 2008, and 37% in 2013. (The reason for the increase between 2008 and 2013 is not clear.) There is some evidence to suggest that the anticipation of discrimination, and the self-stigma which partly arises from this, might be greater than the likelihood of actually experiencing discrimination. Whilst 13% of respondents with a mental health problem said they had been discouraged by others from attending an event, 22% said they had themselves chosen to avoid a social event because of the way they thought people would treat them. Note that this latter figure was even higher (33%) for those in the lowest income group.
6.18 There were two main aspects of the experience of those with mental health problems which demonstrated substantial change over time. Again, the reasons for these changes are unclear. First, the proportion of those with mental health problems who received a positive message about their recovery from professionals, and from family and/or friends, has declined. Sixty-five percent of people with mental health problems received a positive message from professionals about their recovery in 2013 compared with 73% in 2008. Similarly, 66% received a positive message from family and/or friends about their recovery in 2013 compared with 79% in 2008. Further work should be directed at understanding the reasons for this change.
6.19 Second, the extent to which particular factors were identified by those with experience of a mental health problem as helping their recovery have changed quite substantially since 2008. There was consistency in the extent to which respondents chose 'medication' as a supporting factor (about two-fifths in 2008 and 2013) and 'developing my own coping strategies' (about one-quarter on each occasion). However, the proportion choosing 'support from family or friends' decreased substantially (from 62% to 41%) as did the proportion choosing 'having belief in myself' (from 31% to 15%). By contrast, the proportion choosing 'other forms of treatment/therapy' increased (from 19% to 27%) as did the proportion choosing 'finding out more about mental health' (from 8% to 19%). Additional research is needed to explain these changes.
6.20 In 2013, as in previous years, attitudes to mental health varied between socio-demographic subgroups. Across a range of attitudes women showed more tolerant and inclusive attitudes than men, whilst older people, aged 65 and over, were more likely than others to hold stigmatising attitudes. Those with higher levels of education, managerial and professional occupations, and higher incomes were less likely to hold stigmatising attitudes than those with no formal educational qualifications, those in routine or semi-routine occupations and those with lower incomes.
6.21 In addition, a range of other social attitudes were associated with the likelihood of holding stigmatising attitudes. In particular, believing that increased ethnic diversity would cause Scotland to lose its identity was associated with a greater likelihood of holding stigmatising attitudes, whilst believing that 'most people can be trusted' was associated with a lower likelihood of holding stigmatising attitudes.
6.22 In addition, analysis of SSA 2013 also showed that across a range of attitudes, those who have experienced a mental health problem themselves or who know someone with a mental health problem were less likely than others to hold stigmatising attitudes. This reinforces previous findings from earlier SSA surveys (Ormston et al, 2011).
6.23 The differences by gender and age may be at least partly explained by the differential extent to which particular subgroups have personal experience of a mental health problem. Consistently, women and those aged under 55 have reported more personal experience of mental health problems whilst conversely men and older people have reported less personal experience.
6.24 In conclusion, the prevalence of stigmatising attitudes towards those with mental health problems has remained fairly stable over the last decade. The myths and stereotypes attached to people with mental health problems have not substantially reduced over this period. With the evidence indicating that those who know someone with mental health problems are less likely to hold stigmatising attitudes, continued focus on work to break down the barriers which prevent people with mental health problems being open about their condition should decrease stigma and prejudice in the longer term.
Email: Fiona MacDonald