Attitudes to Mental Health in Scotland: Scottish Social Attitudes Survey 2013

1 Introduction

Background

1.1 In 2008, as part of its National Performance Framework, the Scottish Government set out its ambition to be a fair and inclusive society with opportunities for all its citizens to flourish^[1]. This report focuses on one particular group of citizens - those with mental health problems^[2] - and explores public attitudes to those experiencing mental health problems. This is a large group, with approximately one in four people experiencing some kind of mental health problem in any given year according to recent estimates^[3].

1.2 The report presents findings from the 2013 Scottish Social Attitudes survey (SSA) and provides a detailed picture of public attitudes towards mental health problems in 2013. The report examines the extent to which individuals with mental health problems are able to live free from stigma, discrimination, injustice and inequality, and also explores attitudes to recovery among those who identified themselves as having or having had a mental health problem. Moreover, as this is the fifth time that the questions have been asked during the period 2002-2013 (see Paras 1.21-1.23 below) this report also provides valuable insight into whether - and if so how - public attitudes in this area are changing over time.

1.3 This introductory chapter outlines the rationale, context and aims of the survey, discusses why attitudes to mental health problems are of critical importance, outlines the previous research which has been undertaken, and summarises the report structure and conventions.

Research questions

1.4 This report presents findings on three key questions:

• How have attitudes to people with mental health problems changed over time?
• What factors are related to people's attitudes towards people with mental health problems?
• For those with direct experience of mental health problems, what have the social impacts been, what has helped or hindered their recovery, and have they received positive messages about their recovery?

Policy context

1.5 The mental health and wellbeing of populations has become an increasing global priority since the recommendations of the first major report on this topic (World Health Organisation (WHO), 2001) were adopted by the World Health Assembly of the WHO in 2002. From this time, there has been a focus on the importance of adopting policies and practices which would reduce stigma and discrimination, and aid recovery^[4]. Indeed, the 2001 WHO report gave renewed emphasis to UN principles set out a decade earlier on the protection of persons with mental health problems and the improvement of mental health care which asserted that there should be 'no discrimination on the grounds of mental illness'^[5].

1.6 In Scotland post-devolution, the focus on improving mental health and mental wellbeing was initially addressed through the National Programme for Improving Mental Wellbeing (hereafter referred to as 'the National Programme') which was launched in October 2001 and ran until 2008. The National Programme formed part of the then Scottish Executive's wider policy on improving health and reducing inequalities. It articulated a vision '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'.

1.7 Through its lifetime the National Programme focused on raising awareness and promoting mental health and wellbeing; eliminating discrimination; preventing suicide; and promoting and supporting recovery. The legislative context for the National Programme was informed by the Human Rights Act (1998), which sets out the basic rights and freedoms to which all humans are entitled, and the Mental Health (Care and Treatment) (Scotland) Act 2003, which was designed to ensure that free and informed consent forms the basis of treatment for people experiencing mental health problems. A range of initiatives (see Paras 1.8-1.10 below) was launched during the early years of the National Programme.

1.8 'See me'^[6], the national campaign in Scotland, launched in 2002 (and initially funded by the then Scottish Executive) to tackle stigma and discrimination, used 'social marketing'^[7] approaches including: national publicity campaigns delivered through paid for advertising, supported by news and features targeted at the general population; targeted publicity campaigns aimed at specific groups or environments through, for instance, young people and workplace strands; work with journalists; and support for local activity through the provision of materials, advice and guidance. In 2013 it was reviewed by the Scottish Government and the re-launched 'see me' was launched in Nov 2013 (see Para 1.12).

1.9 The suicide prevention strategy 'Choose Life' (Scottish Government, 2002a) was also launched in 2002. Objectives for 'Choose Life' included raising awareness of the risk and protective factors for suicide; ensuring earlier and more effective care and support; improving and increasing the provision of services; removing stigma; providing support to families; improving the sensitivity of media reporting of suicide; and improving data collection. In addition Breathing Space^[8] was launched as a free, confidential phone and web based service for people in Scotland experiencing low mood, depression or anxiety.

1.10 The Scottish Recovery Network (SRN), also funded by the Scottish Government, was launched in 2004 to promote and support recovery from mental health problems. A key element of the SRN's strategic plan is to ensure that mental health services and support are provided in a way which focuses on recovery. In addition, NHS Health Scotland was designated as a WHO Collaborating Centre for Health Promotion and Public Health Development in 2005.

1.11 Policy approaches to improving mental health and wellbeing and to reducing the stigma, discrimination, and social isolation experienced by those with mental health problems have continued to evolve in recent years. Towards a Mentally Flourishing Scotland: Policy and Action Plan 2009-2011 (Scottish Government, 2009a) identified six strategic priorities^[9] one of which, 'improving the quality of life of those experiencing mental health problems and mental illness', relates to reducing discrimination and stigma, and promoting social inclusion, physical health, and recovery. Most recently, following the introduction of the Equality Act 2010, which provided legal rights for disabled people (including those with mental health problems), the Scottish Government published The Mental Health Strategy for Scotland: 2012-2015 (Scottish Government, 2012). This identified seven themes^[10] including two on discrimination and recovery which are particularly pertinent to the module of questions developed for SSA 2013.

1.12 In 2013, a new £4.5 million investment to build on the 'see me' campaign, funded jointly by the Scottish Government and Comic Relief, was announced^[11]. The new three year programme^[12] is focused on building a broad movement of people in Scotland to tackle stigma and discrimination and changing behaviour in targeted settings to bring increased equality and life opportunity to people with mental health problems.

1.13 Most recently, SRN launched a new website 'Write to Recovery' where people can write and publish their stories as a way of promoting and supporting mental health recovery^[13]. The Scottish Government also produced an updated suicide prevention strategy in 2013 (Scottish Government, 2013).

1.14 In Europe the Anti-Stigma Programme European Network (ASPEN)^[14], founded in 2009, is a consortium of 20 EU partner sites (including the Mental Health Foundation in Glasgow) which aims to contribute towards the reduction of stigma and discrimination of people with depression and to communicate this knowledge to all relevant stakeholders. The most recent European Mental Health Action Plan (WHO, 2013), also places stigma and discrimination centre stage. The Plan highlights issues of non-engagement with services, lack of awareness, the promotion and dissemination of sound educational programmes, a rights based approach, and the importance of undertaking anti-stigma activities in communities.

1.15 Thus, the approaches in Scotland are highly congruent with those pursued in Europe and elsewhere. Indeed, a review of the first phase (2003-2006) of the National Programme concluded that 'Scotland is now known in WHO and the European Union as an exemplar of policy development and implementation in public mental health and has influenced policy in other countries' (NHS Health Scotland, 2008b).

1.16 In terms of the wider socio-economic context, there was considerable change in economic and social conditions during the period in which the surveys, which form the basis of the analysis in this report, were conducted (2002-2013). These changes encompassed the global economic crisis, domestic public sector budget constraint, changes in employment opportunities, and changes in the value of household incomes. There is interest in the impacts of the recession and policy changes on health and wellbeing outcomes and on whether public attitudes may have shifted on particular social issues (which could include mental health) as a result of individuals' responses to the economic downturn. However, given the limitations of the cross-sectional survey approach, any changes which are found between the pre and post-recession periods in the data compared in this report cannot be directly attributed to the changing economic situation. This would require further research.

What is a stigmatising attitude in relation to mental health problems and why do attitudes matter?

1.17 In discussing action to tackle stigma and discrimination in relation to mental health problems, policy makers are most often referring to stigmatising and discriminatory behaviour - 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. This report does not explore discriminatory behaviour towards this group; rather the focus is on 'stigmatising attitudes'. The definition of a 'stigmatising attitude' employed in this report in relation to those with mental health problems (first developed for SSA 2002 which included a module of questions on discrimination of all kinds) is:

'One that directly or indirectly suggests that some social groups may not be entitled to engage in the full panoply of social, economic and political activities that are thought to be the norm for most citizens. In short, it is an attitude that openly or tacitly legitimates some form of social exclusion.'

1.18 Policy makers should be interested in stigmatising attitudes as well as in discriminatory behaviours. First and foremost, attitudes often underpin behaviours. If the public believe that people with mental health problems should not be entitled to share the same rights and resources as others, then they are more likely to express this view through action that excludes individuals from that group. Second, even where people's attitudes do not translate into specific discriminatory behaviour, it might be argued that reducing the prevalence of stigmatising attitudes is an important part of building good relations between all sections of society. The importance of challenging stigmatising attitudes more generally (and not just in relation to those people with mental health problems) has been increasingly recognised, for example, in the 'One Scotland, many cultures' campaign^[15].

1.19 Note that it is perfectly possible for discriminatory actions to occur in the absence of such attitudes - for example as a result of bias in institutional procedures or practice. As such, where the report states that stigmatising attitudes appear to be uncommon, this does not imply that discrimination itself is uncommon or that people with mental health problems are not likely to experience this.

Previous research

1.20 The first National Scottish Survey of Public Attitudes to Mental Health, Mental Wellbeing and Mental Health Problems (the Well? What do you think? survey) was commissioned in 2002 to provide baseline data in relation to the National Programme. Further rounds of the Well? What do you think? survey series (referred to in what follows as the Well? survey(s)) were commissioned in 2004, 2006, and 2008, and these were used to track progress and help influence the work of the National Programme in relation to specific outcomes and objectives^[16]. The objectives of the research were to:

• Investigate people's perceptions of their own general health and lifestyle
• Explore people's understanding of mental wellbeing and mental health problems, and their understanding of the factors affecting these
• Investigate people's direct experience of mental health problems and recovery from mental health problems
• Explore people's attitudes to mental health problems, including stereotypes and myths
• Explore people's attitudes to those who experience specific symptoms of mental health problems.

1.21 In relation to 2013, it was agreed to repeat a reduced set of questions which would focus mainly on attitudes, and which would not cover people's knowledge and personal wellbeing in great detail. It was also agreed that rather than conducting a separate survey focusing on mental health alone, the questions should be administered as a module on SSA. Questions about people's perceptions of their own health and lifestyle, their understanding of factors affecting mental health, and their sources of information on mental health problems were therefore omitted. The remaining questions concentrated on attitudes towards mental health problems, including stereotypes and myths; attitudes to those who experience specific mental health conditions; and people's direct experience of mental health problems and recovery.

1.22 Given that many of the questions included in SSA 2013 were also asked in the four Well? surveys, it is possible in principle to examine change over time. However, we comment below (see Para 1.25) on methodological issues which might impact on the comparisons.

Report structure

1.23 The remainder of the report is structured as follows:

• Chapter two discusses people's own personal experience of mental health problems and indirect experience through knowing family or friends who have had a mental health problem; whether or not people tell others about their mental health problems; and the social impact of having a mental health problem
• Chapter three looks at attitudes to recovery and the nature of the messages people with mental health problems receive about recovery from professionals, and from family and/or friends
• Chapter four summarises the findings on general perceptions of people with mental health problems, including myths and stereotypes
• Chapter five focuses on attitudes to those who experience specific mental health problems
• Chapter six summarises the main findings and conclusions.

About the data

1.24 The Scottish Social Attitudes survey was established by ScotCen Social Research, an independent organisation based in Edinburgh and part of NatCen Social Research, the UK's largest independent social research agency. The survey provides robust data on changing social and political attitudes to inform both public policy and academic study. Around 1,500 face-to-face interviews are conducted annually (1,497 in 2013) with a representative probability sample of the Scottish population. Interviews are conducted in respondents' homes, using computer assisted personal interviewing. Most of the interview is conducted face-to-face by a ScotCen interviewer, but some questions each year are asked in a self-completion section. The survey has achieved a response rate of between 54% and 65% in each year since 1999 (in 2013, the response rate was 55%). The data are weighted to correct for over-sampling, non-response bias and to ensure they reflect the sex-age profile of the Scottish population. All sample sizes shown below the charts and tables show unweighted bases. Further technical details about the survey are included in Annex B.

1.25 Methodological changes were implemented between the Well? survey series and SSA 2013. There were changes to the method of data collection for questions asked of those who had experienced mental health problems (face-to-face in the Well? survey series and self-complete in SSA 2013). There were also some alterations to question wording and question ordering^[17]. While these methodological differences are unlikely to affect the substantive conclusions, they do mean that some caution is required in interpreting trends.

Limitations of the data

1.26 The Scottish Social Attitudes survey is a quantitative survey which focuses on producing robust and reliable population estimates across a wide range of substantive topics. In common with other general population surveys, individuals living in specific settings where the incidence of mental health problems is known to be high (e.g. prisons, hospitals, residential care facilities) are not included in the sample. The survey does not allow questions about respondents' motivations or feelings to be examined in depth; this would require more detailed research using qualitative methods.

1.27 Questions for the SSA survey are developed through a rigorous and detailed process involving cognitive testing and extensive piloting. There is also discussion on a question-by-question basis of whether the most suitable approach is to use face-to-face or self-complete methods. This ensures that as far as possible questions will be interpreted in a uniform fashion, and that any social desirability bias - especially in relation to sensitive questions - will be minimised. However, it is acknowledged that variation in how questions are interpreted by respondents and the possibility of social desirability bias in such a complex area as mental health cannot be completely eliminated.

Analysis and reporting conventions

1.28 All percentages cited in this report are based on the weighted data (see Annex B for details) and are rounded to the nearest whole number. All differences described in the text (between years, or between different groups of people) are statistically significant at the 95% level or above, unless otherwise specified. This means that the probability of having found a difference of at least this size, if there was no actual difference in the population, is 5% or less. The term 'significant' is used in this report to refer to statistical significance, and is not intended to imply substantive importance. Further details of the significance testing and multivariate analysis conducted for this report are included in Annex B.