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

4 Public Perceptions of Mental Health Problems

4.1 This chapter examines attitudes towards and understanding of mental health problems. All respondents (1,497) were asked how much they agreed or disagreed with nine statements about mental health^[29]. The same set of statements was included in each of the four previous Well? surveys which ran between 2002 and 2008. This means we are able to explore change over time.

4.2 These statements covered a wide range of issues including: their own individual attitudes towards people with mental health problems; their understanding of the causes and consequences of mental health problems; and the ways in which others and wider society perceive and treat people with mental health problems.

4.3 The nine statements were:

• If I was suffering from mental health problems, I wouldn't want people knowing about it;
• The public should be better protected from people with mental health problems;
• Anyone can suffer from mental health problems;
• I would find it hard to talk to someone with mental health problems;
• People are generally caring and sympathetic to people with mental health problems;
• People with mental health problems are often dangerous;
• The majority of people with mental health problems recover;
• People with mental health problems should have the same rights as anyone else; and
• People with mental health problems are largely to blame for their own condition.

4.4 The difficulties faced by many people with mental health problems are exacerbated by the stigma and discrimination they face, at work, within the family, and as part of their local community. The stigma around mental health problems means that people often do not wish to talk about or seek help (Jorm, 2000; Scottish Government 2012). As we have already seen, those who knew someone with a mental health problem had different attitudes from those who did not. Other studies have shown that direct social contact with people with mental health problems can change attitudes (McDaid, 2008). The 'see me' programme (see Paras 1.8 & 1.13) aims to fully engage people with lived experience of mental health problems and others in an active process of overcoming stigma and discrimination, focused on achieving behaviour change in specific settings and publicly to end the negative impacts of stigma and discrimination.

4.5 Evidence from the SSA in 2010 (Ormston et al, 2011) showed that stigmatising attitudes towards people who experience depression from time to time were fairly prevalent. Two in five people felt that someone who experienced depression from time to time was unsuitable to be a primary school teacher, the second highest level among the nine distinct social groups who were asked about^[30]. However, this had decreased from 51% in 2006. Views were somewhat less negative when asked whether they would feel unhappy if a member of their family married someone who experiences depression from time to time; 21% said they would feel unhappy.

Approach to analysis

4.6 Responses to each of nine statements were recorded on a five-point agree-disagree scale. The statements divide into those for which:

• a response of 'agree' or 'strongly agree' can be seen as a positive response^[31], demonstrating an awareness of the issue or a lack of prejudice;
• a response of 'agree' or 'strongly agree' can be seen as a negative response^[32];
• and one, that 'people are generally caring and sympathetic to people with mental health problems', which is ambiguous^[33].

4.7 In order to provide a structure for the analysis, we have grouped these nine statements into three categories: knowledge, understanding and awareness (4 items); stigma (2 items): and individual and public rights (3 items).

4.8 In terms of sub-group analysis, we examined a wide range of socio-demographic, experiential and attitudinal factors collected on the survey which were expected, on the basis of previous research, to have an association with people's attitudes to mental health problems. The factors were:

• Socio-demographic factors (age, gender, income, level of education, social class, urban-rural and area deprivation)
• Experience of mental health (personal experience or knowing someone with mental health problems)
• Social attitudes (levels of trust, community support and attitudes to ethnic diversity)

4.9 The social attitudes measures are based on a range of different questions which were included in other SSA 2013 modules. The questions on levels of social trust and community support were collected as part of the core module on SSA 2013 funded by the Scottish Government^[34]. The question measuring levels of social trust was: 'Generally speaking, would you say that most people can be trusted, or that you can't be too careful in dealing with people?' A range of measures of levels of community support were included in SSA 2013. The question used in this chapter was how much people agreed or disagreed that: 'If my home was empty, I could count on one of my neighbours to keep an eye on it.'

4.10 The questions on attitudes to ethnic diversity were funded by the ESRC as part of a module on the constitutional future of Scotland. In SSA 2013 respondents were asked if they agreed that Scotland would lose its identity if more Muslims, more blacks and Asians, or more Eastern Europeans came to live here. These questions are used here as a measure of the acceptance of diversity within Scotland. Previous evidence from SSA 2010 (Ormston et al, 2011) showed a significant association between agreeing that Scotland would lose its identity if it were more ethnically diverse and acceptance that 'sometimes there is good reason for people to be prejudiced against certain groups'.

4.11 We have highlighted important sub-group differences in the text, with more detailed tables provided in Annex A. Important differences have been determined through a combination of tests of statistical significance and regression analysis^[35].

Knowledge, understanding, and awareness

4.12 Table 4.1 below shows the levels of agreement with the four statements which relate to knowledge, understanding and awareness, and how these have changed over time.

Table 4.1: Level of agreement with statements demonstrating knowledge, understanding and awareness of mental health issues, 2002 to 2013

	% Strongly agree/Tend to agree
	2002	2004	2006	2008	2013
Anyone can suffer from mental health problems	98	97	97	93	98
People are generally caring and sympathetic to people with mental health problems	36	39	40	40	39
The majority of people with mental health problems recover	50	46	46	42	33
People with mental health problems are largely to blame for their own condition	7	6	4	4	5
Sample size	1381	1401	1216	1177	1497

Anyone can suffer from mental health problems

4.13 Anyone can experience a mental health problem, and indeed, around one in four people do each year^[36]. Mental health problems can be triggered by a range of factors, including childhood abuse, social isolation, poverty, poor housing, the death of someone close, trauma, head injury, long-term physical ill-health, stress, and caring for a partner or someone close^[37]. Misuse of drugs or alcohol may sometimes lead to poor mental health, but the direction of causality is more commonly in the other direction (Frisher et al, 2005).

4.14 In 2013, 98% agreed with the statement that anyone can suffer from mental health problems. There has been very little change in this figure since the first Well? survey in 2002, except for a slightly anomalous result in 2008. It appears that the public understand that mental health problems are widespread.

4.15 With such a high figure, it is not surprising to find that there is little variation between attitudes in terms of age, education, area deprivation or other factors (for full details see Table A.11 in Annex A). Most people in all sub-groups recognised that anyone can suffer from mental health problems. However, there was some significant variation in the percentage who 'strongly agreed' with this statement. In particular, 79% of those who knew someone with a mental health problem agreed strongly that anyone can suffer from mental health problems compared with only 61% of those who did not know anyone with a mental health problem.

The majority of people with mental health problems recover

4.16 There is an increasing focus on recovery in mental health, both in Scotland and internationally. However, as discussed in Chapter 3 (Para 3.3), 'recovery' may be interpreted in a variety of different ways by both members of the public and those who have experienced mental health problems. The aim of recovery-based approaches is to support people to be able to live meaningful and satisfying lives, with or without the presence of symptoms.

4.17 A third in 2013 (33%) thought that 'the majority of people with mental health problems recover'. This has fallen from a half (50%) in 2002. The reasons for this are not clear. It may reflect a change in the interpretation of the term 'recover' in this context, which may be viewed by some to mean a definitive 'cure' or symptom-free life, while for others it may represent a more nuanced idea of living well and managing with ongoing symptoms. As noted in Para 3.20, in-depth exploration of people's understanding of 'recovery' would be needed before drawing any conclusions about factors driving this change over time.

4.18 Whether someone has personal experience of mental health problems^[38] is associated with the belief that 'the majority of people with mental health problems recover'. Forty-four percent of those who had experienced mental health problems agreed that 'the majority of people with mental health problems recover' compared with 30% of people who had never experienced a mental health problem (Figure 4.1 below).

4.19 Sub-groups which had a more pessimistic view about recovery included men and younger people^[39]. Those in the lowest income group appeared to be most optimistic about the possibility of recovery, a finding that remained significant even when other factors were taken into account. In particular, 40% of those with a household income of up to £14,300 a year agreed that the majority recover, compared with 30% of those earning over £44,200 a year (see Table A.12 in Annex A).

Figure 4.1: 'The majority of people with mental health problems recover' by personal experience of mental health problems (2013)

Base: all respondents.
Sample size: 341 (personal experience); 973 (no personal experience); 26 (Can't choose/refused)

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

4.20 Nine out of ten people (89%) disagreed that 'people with mental health problems are largely to blame for their own condition', while just 5% agreed with the statement. These figures have remained fairly stable since the first Well? survey in 2002.

4.21 Neither personal experience of mental health problems, nor knowing someone with a mental health problem, was significantly associated with believing that people with mental health problems are largely to blame for their own condition. Differences were seen in terms of gender, education, and socio-economic classification^[40] (for full details see Table A.13 in Annex A). Men (6%), those in routine or semi-routine occupations (10%), and those with no educational qualifications (9%) were the most likely to agree that people are to blame for their own condition (compared with 3% of women, 2% in managerial and professional occupations, and 2% of those with degrees).

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

4.22 As suggested earlier, the level of agreement with the statement that 'people are generally caring and sympathetic to people with mental health problems' can be interpreted in different ways. For example, it may be an indicator of the level of public sympathy, or it could indicate a lack of awareness by respondents of the stigmatisation and discrimination experienced by people with mental health problems. In 2013, 39% of people agreed that people are 'sympathetic to people with mental health problems'. As Table 4.1 (above) shows, there has been very little change in the proportion agreeing with this statement over the last decade. Those working in public health policy, services and advocacy would like to see both more sympathetic attitudes towards those with mental health problems and greater awareness and reduced acceptability of mental health-associated stigma and discriminatory behaviour. It is difficult to say whether an increase or a decrease in the 39% in agreement would be seen as a positive change given the different ways in which the data could be interpreted.

4.23 Among those who have had personal experience of mental health problems about a quarter agreed that 'people are generally caring and sympathetic to people with mental health problems'. This is substantially lower than the figure for the population of Scotland as a whole. It could be argued that the views of people with mental health problems are the best indication of how caring people really are towards those with mental health problems as their perspective will be shaped by their direct personal experience.

4.24 Those who were more likely to agree that people are caring and sympathetic to those with mental health problems included men, those aged under 25, and those aged 65 or above, the self-employed, those in routine or semi-routine occupations, those with no qualifications, and those who did not know anyone with a mental health problem (for full details see Table A.14 in Annex A).

Stigmatisation of people with mental health problems

4.25 Table 4.2 shows the level of agreement with the two statements which indicate levels of stigma towards those with mental health problems.

Table 4.2: Strongly agree/tend to agree with statements demonstrating the stigma towards those with mental health problems, 2002 to 2013

	% Strongly agree/Tend to agree
	2002	2004	2006	2008	2013
If I was suffering from mental health problems, I wouldn't want people knowing about it	50	45	41	44	47
I would find it hard to talk to someone with mental health problems	20	15	17	15	17
Sample size	1381	1401	1216	1177	1497

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

4.26 Almost half (47%) said that if they were suffering from mental health problems, they 'wouldn't want people knowing about it', a figure that has only changed slightly since 2002. The survey does not gather data on the various reasons why individuals would or do not want others to know about their mental health problems.

4.27 Of the factors listed in Para 4.7, only one of them, the measure of community support experienced by people, was significantly associated with whether or not one would want other people to know about one's mental health problems (Figure 4.2 below). Those who felt they could rely on a neighbour to look after their home if it were empty were much less likely than those who could not to say they would not want people to know if they had mental health problems (for full details see Table A.15 in Annex A).

Figure 4.2: 'If I were suffering from a mental health problem I wouldn't want people knowing about it' by whether could rely on a neighbour (2013)

Don't know was chosen by 1% or less.
Base: all respondents
Sample size: 1312 (could rely on neighbour); 130 (could not rely on neighbour)

4.28 For those who said they had personally experienced a mental health problem at some point in their life time^[41], we examined how their responses to this statement related to whether they actually told people about their mental health problems, or not. Figure 4.3 below shows that even among those who wanted people to know about their mental health problems, the people they would tell would be largely limited to family and friends. The only significant difference between those who would not want people to know and those who would was in terms of telling more distant people. Five percent of those who agreed they would not want people to know had told people they did not know well about their mental health problem, compared with 14% of those who said they would want people to know.

Figure 4.3: Whom have told about mental health problem, by whether would want people to know about own mental health problems (2013)

Base: All those who said they had experienced a mental health problem
Sample size: 191 (wouldn't want people to know); 161 (would want people to know)

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

4.29 Around one in six (17%) said that they 'would find it hard to talk to someone with mental health problems', a figure which has changed little since 2002. Thus, it appears that people are much more concerned about people knowing about their own problems than they are about talking with others with mental health problems.

4.30 There was greater variation between sub-groups with respect to whether people would 'find it hard to talk to someone with mental health problems' compared with the statement about whether people would want others to know about their own mental health problems (for full details see Table A.16 in Annex A). Those who were more likely to agree they would 'find it hard to talk to someone with mental health problems' were: men, those aged 65 or above, the self-employed, those with no qualifications^[42], those who did not know anyone who has had a mental health problem, those who cannot rely on a neighbour^[43], and those who had negative views about ethnic diversity.

4.31 For example, 26% of those aged 65 or above agreed they would 'find it hard to talk to someone with mental health problems', compared with 10% of those aged between 45 and 54. And 11% of those who knew someone with a mental health problem agreed with this statement, compared with 28% of those who did not. Not surprisingly, the group least likely to find it hard to talk to someone with a mental health problem were those who have personally experienced mental health problems: only 7% of this group agreed with the statement, compared with 19% of those who did not have personal experience.

Individual and public rights

4.32 The final three statements examined attitudes that were more clearly of a discriminatory nature, although they also contain elements of knowledge and understanding, highlighting the point that discrimination is often about a lack of knowledge rather than overt prejudice. These statements were: 'people with mental health problems are often dangerous'; 'the public should be better protected from people with mental health problems'; and 'people with mental health problems should have the same rights as anyone else'.

4.33 While there is some evidence that those with very serious mental health problems may be more likely to commit violent crimes (see for example, Appleby et al, 2014, Fazel et al, 2014, Van Dorn et al, 2012), there is also evidence that they are more likely to be the victims of crime (see, for example, Pettit et al, 2013).

4.34 Table 4.3 below shows the levels of agreement with the three statements about the perceived danger from people with mental health problems and the balance between individual and public rights, and how these have changed over time.

Table 4.3: Level of agreement with statements about perceived danger from people with mental health problems and the balance between individual and public rights (2002 to 2013)

	% Strongly agree/Tend to agree
	2002	2004	2006	2008	2013
People with mental health problems are often dangerous	32	15	16	19	19
The public should be better protected from people with mental health problems	35	24	32	25	28
People with mental health problems should have the same rights as anyone else	88	88	85	86	82
Sample size	1381	1401	1216	1177	1497

People with mental health problems are often dangerous

4.35 Overall, 19% of people agreed with the statement 'people with mental health problems are often dangerous'. This is a slight increase on the level reported in 2004, but well below that reported in 2002. There has been no change at all since 2008.

4.36 There were apparent differences in terms of socio-demographic characteristics^[44], for example, men, those aged 65 or above, and those with Standard grades or no formal educational qualifications were more likely to agree that 'people with mental health problems are often dangerous' (for full details see Table A.17 in Annex A). However, after conducting regression analysis these factors were no longer significant, or were only marginally significant. There were much stronger associations with whether people knew someone with a mental health problem and whether people felt that Scotland would lose its identity if there was more immigration. The suggested reason for the association between attitudes to immigration and stigmatising attitudes to people with mental health problems (see Para 4.9) is that this question taps into people's general levels of acceptance of diversity, prejudice and discrimination.

4.37 Twenty-seven percent of those who did not know someone with a mental health problem, compared with 15% of those who did, agreed that 'people with mental health problems are often dangerous'. Around a quarter (26%) of those who agreed that more immigration from specific groups would lead to Scotland losing its identity agreed that 'people with mental health problems are often dangerous', compared with 13% of those who did not (Figure 4.4 below).

4.38 Personal experience of mental health problems, and whether people felt that most people can be trusted were also associated^[45] with believing that 'people with mental health problems are often dangerous' (Figure 4.4 below). Those with personal experience of mental health problems and those who thought most people could be trusted were less likely to agree that 'people with mental health problems are often dangerous'.

Figure 4.4: 'People with mental health problems are often dangerous' by attitudes to ethnic diversity and personal experience of mental health problems

Don't know was chosen by 1% or less
Base: all respondents
Sample size: 854 (agreement with immigration statement); 435 (disagreement with immigration statement); 341 (personal experience of mental health problems); 973 (no personal experience)

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

4.39 Over a quarter of people (28%) agreed that 'the public should be better protected from people with mental health problems'. The proportion agreeing with the statement has fluctuated over the years, with the largest change between 2002 and 2004. The figure for 2013 is not significantly different from that in the 2008 Well? survey.

4.40 As with the previous statement, knowing someone with mental health problems reduced the likelihood of agreeing that the public should be better protected. Twenty-four percent of those who knew someone with a mental health problem agreed that 'the public should be better protected from people with mental health problems', compared with 36% of those who did not. Those who agreed that increased immigration would lead to Scotland losing its identity were more likely to agree that 'the public should be better protected from people with mental health problems'. Thirty-six percent of those who agreed that increased immigration would lead to Scotland losing its identity agreed that the public should be better protected, compared with 17% who disagreed. Having no formal educational qualifications, being aged 65 or above, and not having neighbours to turn to for support were also all associated with higher levels of agreement that the public should be better protected (for full details see Table A.18 in Annex A).

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

4.41 Eighty-two percent agreed that 'people with mental health problems should have the same rights as anyone else'. This has fallen from 88% in 2002. While this finding is likely to be disappointing to those who defend and seek to improve the rights of people with mental health problems, the reasons for the change are not clear.

4.42 The strongest predictor of disagreement that people with mental health problems should have the same rights was attitudes to ethnic diversity. Eleven percent of people who agreed that increased immigration would affect Scotland's identity disagreed that 'people with mental health problems should have the same rights as anyone else', compared with 5% of those who disagreed that increased immigration would negatively affect Scotland's identity. Not trusting people in general and not being able to turn to neighbours for advice and support were also associated with disagreement with the statement, as was having no personal experience of mental health problems (for full details see Table A.19 in Annex A).