Scottish Health Survey 2015 - volume 1: main report

1 Mental Health And Wellbeing

Line Knudsen

Summary

• Overall, average levels of wellbeing for adults have changed little since 2008, with WEMWBS scores ranging from 49.7 to 50.0 over this period (49.9 in 2015).
• Levels of wellbeing remained similar for men and women overall but were significantly lower in 2015 for women aged 16-24 (47.9) than for other age groups of men or women.
• Wellbeing among 13 to 15 year olds decreased with age for all children (52.3 for those aged 13 compared with 50.0 for those aged 15).
• The average score for 13 to 15 year old boys (52.0) was significantly higher than for girls of the same age (49.9).

• Prevalence of anxiety increased from 9% of adults having two or more symptoms in 2012/2013 to 12% in 2014/2015.
• The proportion of women with two or more symptoms of anxiety (15%) was higher than the proportion for men (9%).
• The proportion of adults with two or more symptoms was highest for those aged 16 to 64 in 2012-2015 (10-13%) and lowest for those aged 75 and over (5%).
• The prevalence of those with two or more symptoms of depression in 2014/2015 was 10%, with this being a similar level to those in recent years.
• Those in the most deprived quintile were more likely than those in the least deprived quintile in 2012-2015 to have two or more symptoms of anxiety (15% compared with 7%). A similar pattern was seen for those with two or more symptoms of depression (16% in the most deprived areas compared to 4% in the least deprived).

• Self-reported levels of self-harm increased from 3% in 2008/2009 to 7% in 2014/2015.
• In 2012-2015, levels were highest among those aged 16-24 in 2012-2015 (18%) and, particularly, women in that age group (23%).

• The proportion of adults who reported to have ever attempted suicide was 6% in 2014/2015.
• Prevalence of having ever attempted suicide was higher in the most deprived areas (10%) than in the three least deprived areas (3-4%) in 2012-2015.

• The proportion of children aged 4-12 who had a borderline or abnormal total difficulties score decreased from 2003 (17%) to 2014/2015 (14%).
• Children in the most deprived areas were more likely to have a borderline or abnormal total difficulties score (22%) than those in the least deprived (6%) in 2012/2015, with prevalence for boys much higher than for girls (18% compared with 10%).

1.1 Introduction

This chapter looks at the mental health and wellbeing of both adults and children. Mental wellbeing, together with physical and social wellbeing, is one aspect of overall wellbeing. It is important as an indicator of quality of life. Like many of the other topics covered in this report, mental wellbeing is a critical measure of the population's overall health status and a key marker of health inequalities ^[1] .

The World Health Organisation ( WHO) considers mental wellbeing to be fundamental to their definition of health ^[2] .Mental disorders often co-exist with other diseases, including cancers and cardiovascular disease, and many of the risk factors covered in this report, such as obesity, excessive alcohol consumption, and low levels of physical activity, are common to both mental disorders and other non-communicable diseases, with outcomes being critically interdependent.

Mental disorder represents a significant public health challenge globally. Those with mental disorders have disproportionately higher disability and mortality than the general population, dying on average more than 10 years earlier ^[3] .Neuropsychiatric disorders are the second largest contributor to the burden of disease in Europe and mental disorders account for around 40% of all years lived with disability ^[3] . Accounting for 4.3% of the global burden of disease, depression is now the largest single cause of disability worldwide (11% of all years lived with disability globally)and is the leading chronic condition in Europe ^[2,3] .Inequalities in mental health and wellbeing exist. Globally, depression is more prevalent among women than men ^[2] , while, throughout Europe, prevalence of most mental disorders is higher among those living in more deprived areas ^[3] .

Low mental wellbeing and mental ill-health in childhood often lead to problems in adult life[4]. The same is true for more general social and behavioural problems in childhood[5,6] ^,. Hence indicators of social, emotional and behavioural development in children can be used to help predict the likely future burden on society not just in health terms, but more widely in terms of criminal behaviour or unemployment.

1.1.1 Policy background

The Mental Health Strategy for Scotland: 2012-2015 ^[3] , published in August 2012, has now come to an end. It set out the Scottish Government's key commitments in relation to improving the nation's mental health and wellbeing and for ensuring improved services and outcomes for individuals and communities. The strategy promoted safe, effective and person-centred health and care. In addition to focussing on improved service delivery there was also an emphasis on the actions that individuals and communities could take to maintain and improve their own health.

Examples of this approach include the Living Life Guided Self Help Service operated by NHS 24, the Steps for Stress resources managed by NHS Health Scotland, and Ginsberg - a web-based tool launched by the Scottish Government to help people manage their wellbeing in relation to other aspects of their lives. Ginsberg allows people to see patterns that are developing, to draw links between what they are doing with their time and how they are feeling, and to see the changes they can make to improve their wellbeing.

As part of the process to update the strategy, a paper has recently been published on research and mental health policy, to improve the impact of research, and the evidence base for future policy ^[7] .

Supporting the Scottish Government's overall purpose, the 2012-2015 strategy built upon the work of a number of key policy documents including Delivering for Mental Health ^[8] (published in 2006), and Towards a Mentally Flourishing Scotland ^[9] , which covered the 2009-2011 period. The previous strategy was aimed at promoting good mental wellbeing; reducing the prevalence of common mental health problems, suicide and self-harm; and improving the quality of life of those experiencing mental health problems and mental illnesses.

Coinciding with the end of the Choose Life ^[10] ten year national strategy on preventing suicide, the Scottish Government demonstrated its ongoing commitment to reducing suicide in the Suicide Prevention Strategy 2013-2016 ^[11] published in December 2013. The strategy is built around five themes: responding to people in distress; talking about suicide; improving the NHS response to suicide; developing the evidence base; and supporting change and improvement ^[11] . Eleven commitments are included in the strategy, including the commitment that NHS Health Scotland will continue to host the Choose Life National Programme for Suicide Prevention ^[11] .

There are a number of other mental health strategies, including the Autism strategy, the Learning Disability strategy "the keys to life", the dementia strategy and the alcohol framework and road to recovery drug strategy.

One of the Scottish Government's National Outcomes is the overall strategic objective for health: We live longer, healthier lives ^[12] . This is supported by a number of National Indicators including 'improve mental wellbeing' ^[12] which is monitored using data from the Scottish Health Survey ( SHeS). The purpose target to improve healthy life expectancy over the 2007 to 2017 period uses SHeS data for children (aged 0-15) in the calculations used to measure progress. The fact that those with mental disorders die, on average, earlier than the general population impacts on another National Indicator; to 'reduce premature mortality'. Scotland also has a set of national, sustainable mental health indicators for adults and children, covering both outcomes and contextual factors that confer increased risks of, or protection from, poor mental health outcomes ^[13] . SHeS is the data source for 28 of the 54 indicators for adults and over 20 of the indicators for children ^[15] .

There were NHS Scotland HEAT targets for specialist Child and Adolescent Mental Health Services ( CAMHS), and for access to Psychological Therapies (across all ages in the population), to achieve 18 week maximum referral to treatment times ^[16] . In January 2015, the targets become standards in NHS Scotland Local Delivery Plans ^[17] .

Figures for the quarter ending March 2016 show that the target was met for 84% of referrals of children and young people ^[18] . Around 83% of patients (across all ages) starting a psychological therapy met the target during the quarter ending March 2016 ^[16,19] .The Scottish Government has announced additional funding to continue to improve mental health across Scotland and ensure that people get timely access to services.

1.1.2 Reporting on mental wellbeing in the Scottish Health Survey ( SHeS)

This chapter updates trends in mental wellbeing for adults. Figures are also reported for 2015 by age and sex, and for children aged 13-15 by age and sex and by area deprivation for the combined period 2012-2015.

Prevalence of depression and anxiety symptoms and of self-reported, attempted suicide and deliberate self-harm among adults in 2014/2015 is compared with prevalence in earlier years of the survey. Patterns by age and sex, and by area deprivation, are also reported for 2014/2015.

This chapter finishes by reporting on the social, emotional and behavioural development of children aged 4-12, as measured by Goodman's Strengths and Difficulties Questionnaire ( SDQ).

1.2 Methods and definitions

1.2.1 Warwick-Edinburgh Mental Wellbeing Scale ( WEMWBS)

Wellbeing is measured using the WEMWBS questionnaire. It has 14 items designed to assess: positive affect (optimism, cheerfulness, relaxation) and satisfying interpersonal relationships and positive functioning (energy, clear thinking, self-acceptance, personal development, mastery and autonomy) ^[20] . The scale uses positively worded statements with a five-item scale ranging from '1 - none of the time' to '5 - all of the time'. The lowest score possible is therefore 14 and the highest score possible is 70; the tables present mean scores.

The scale was not designed to identify individuals with exceptionally high or low levels of positive mental health so cut off points have not been developed ^[21] . The scale was designed for use in English speaking populations, however in a very small number of cases, the questions were translated to enable the participation of people who did not speak English ^[22] .

WEMWBS is used to monitor the National Indicator ' improve mental wellbeing' ^[12] . It is also part of the Scottish Government's adult mental health indicator set, and the mean score for parents of children aged 15 years and under on WEMWBS is included in the mental health indicator set for children ^[13] .

1.2.2 Depression and anxiety

Details on symptoms of depression and anxiety are collected via a standardised instrument, the Revised Clinical Interview Schedule ( CIS-R). The CIS-R is a well-established tool for measuring the prevalence of mental disorders ^[23] . The complete CIS-R comprises 14 sections, each covering a type of mental health symptom and asks about presence of symptoms in the week preceding the interview. Prevalence of two of these mental illnesses - depression and anxiety - were introduced to the survey in 2008. Given the potentially sensitive nature of these topics, they were included in the nurse interview part of the survey prior to 2012 ^[24] . Since 2012 the questions have been included in the biological module, with participants completing the questions themselves on the interviewer laptop ( CASI). The change in mode of data collection may have impacted response, and comparisons of 2014/2015 figures with pre-2012 figures should be interpreted with caution. There is a possibility that any observed changes in prevalence across this period may simply reflect the change in mode rather than any real change in the population.

The following two mental health indicators are based on the depression and anxiety information collected on the survey:

Percentage of adults who have a symptom score of 2 or more on the depression section of the CIS-R.

Percentage of adults who have a symptom score of 2 or more on the anxiety section of the CIS-R.

1.2.3 Suicide attempts

In addition to being asked about symptoms of depression and anxiety, participants were also asked whether they had ever attempted to take their own life. The question was worded as follows:

Have you ever made an attempt to take your own life, by taking an overdose of tablets or in some other way?

Those who said yes were asked if this was in 'the last week, in the last year or at some other time'. Note that this question is likely to underestimate the prevalence of very recent attempts, as people might be less likely to agree to take part in a survey immediately after a traumatic life event such as this. Furthermore, suicide attempts will only be captured in a survey among people who do not succeed at their attempt.

Since 2012 the questions have been included in the biological module, with participants completing the questions themselves on the interviewer laptop ( CASI). Prior to this they were administered in the nurse interview, and any changes over time need to be interpreted with caution because of the change in mode.

1.2.4 Deliberate self-harm

Since 2008, participants have been asked whether they have ever deliberately harmed themselves in any way but not with the intention of killing themselves. Those who said that they had self-harmed were also asked if this was in the last week, last year or at some other time. The percentage of adults who have self-harmed in the last year is one of the national mental health indicators for adults ^[13] .

Since 2012 the questions have been included in the biological module, with participants completing the questions themselves on the interviewer laptop ( CASI). Again, changes over time need to be interpreted in light of this change in the mode of data collection.

1.2.5 Strengths and Difficulties Questionnaire ( SDQ)

The social, emotional and behavioural development of children aged 4-12 has been measured via the Strengths and Difficulties Questionnaire ( SDQ) ^[25] since 2003. The SDQ is a brief behavioural screening questionnaire designed for use with the 3-16 age group. The SDQ was completed by a parent on behalf of all children aged 4-12.

The SDQ comprises 25 questions covering themes such as consideration, hyperactivity, malaise, mood, sociability, obedience, anxiety and unhappiness. It is used to measure five aspects of children's development: emotional symptoms; conduct problems; hyperactivity/inattention; peer relationship problems; and pro-social behaviour.

A score was calculated for each of the five aspects, as well as an overall 'total difficulties' score which was generated by summing the scores from all the domains except pro-social behaviour. The total difficulties score ranged from zero to forty with a higher score indicating greater evidence of difficulties. There are established thresholds indicating 'normal' (score of 13 or less), 'borderline' (14-16) or 'abnormal' scores (17 or above).

The total and individual SDQ domain scores all feature in the mental health indicators set for children[15] ¹⁵. The indicators are the percentage of children with normal scores for the pro-social domain, and the percentages with abnormal/borderline scores in the other four domains and overall. All these figures are reported in the tables.

1.3 WEMWBS

1.3.1 Trends in adult WEMWBS mean scores since 2008

WEMWBS mean scores for adults aged 16 and over have been relatively static since 2008, ranging from 49.7 to 50.0 across the survey years (49.9 in 2015). Mean scores have not changed significantly for either men or women since 2008, with the mean score for both sexes in 2015 being 49.9. Table 1.1

1.3.2 Adult WEMWBS mean scores in 2015, by age and sex

The WEMWBS mean score for adults was highest for those aged 65-74 (51.0) and lowest for those aged 16-24 (49.1).

Levels of wellbeing varied across age groups for women (as shown in Figure 1A) with a lower level reported for those aged 16-24 (47.9) than for the oldest age groups (50.6 - 51.1 for those aged 65 and over). For men, the variation across age groups was not significant.

Figure 1A, Table 1.2

1.3.3 Child (13-15) WEMWBS mean scores in 2012-2015 (combined), by age and sex, and by area deprivation

For the period 2012-2015 combined, the WEMWBS mean score for all children aged 13-15 was 51.0, with the mean score for boys (52.0) being significantly higher than that for girls (49.9). The WEMWBS mean score was higher among children aged 13 (52.3) than among those aged 15 (50.0), with the same pattern being seen for both boys and girls.

Table 1.3

Age-standardised mean scores for children aged 13-15 did not differ significantly by area deprivation (varying from 50.1 to 51.5 across the deprivation quintiles). Boys and girls followed a similar pattern, with no significant difference by area deprivation. The mean score for boys ranged between 50.9 and 53.1 across the deprivation quintiles with the score for girls varying between 49.0 and 50.6.

Table 1.4

1.4 Depression And Anxiety

1.4.1 Trends in symptoms of depression since 2008/2009 (combined), by sex

In 2014/2015, one in ten (10%) adults exhibited two or more symptoms of depression, indicating moderate to high severity. This level is similar to that reported in the previous survey periods of 2008/2009 (8%), 2011/2012 (8%) and 2012/2013 (9%). The proportion of adults reporting one or more symptoms of depression in 2014/2015 (20%) was significantly higher than the proportion in both 2012/2013 (17%) and 2008/2009 (14%).

The proportion of those with two or more symptoms of depression rose significantly between 2008/2009 and 2014/2015 for men (7% to 10%) but not women (10% in both survey periods). Significant increases were seen in the proportion of both men and women with one or more symptoms (11% to 19% for men, 16% to 21% for women).

Table 1.5

1.4.2 Symptoms of depression in 2012-2015 (combined), by age and sex, and by area deprivation

In 2012-2015, younger age groups were more likely than older age groups to report at least one symptom of depression (18% to 23% of those aged 16-64 compared with 10% to 13% of those aged 65 and over). The proportion of adults reporting two or more symptoms was highest for those aged 35-64 (10-11%) and lowest for those aged 65 and over (6-7%). Patterns of overall prevalence by age were similar for both men and women.

Table 1.6

Those in the most deprived areas were 4 times more likely than those in the least deprived areas to report two symptoms of depression (16% compared with 4%), using age-standardised data. Comparable patterns of prevalence of two or more symptoms of depression increasing with deprivation were seen for both men (18% in the most deprived quintile compared with 6% in the two least deprived quintiles) and women (15% in the most deprived compared with 3% in the least deprived).

Figure 1B, Table 1.7

1.4.3 Trends in symptoms of anxiety since 2008/2009 (combined), by sex

The proportion of adults with two or more symptoms of anxiety, indicating moderate to severe levels of anxiety, showed an increase from 9% in 2008/2009 to 2012/2013 to 12% in 2014/2015. Women were significantly more likely than men to exhibit two or more signs of anxiety (15% compared to 9%). No significant change was observed for men from 2008/2009 to 2014/2015 (7% to 9%) but there was a significant increase for women (11% to 15%).

The proportion of adults with at least one symptom of anxiety rose from 21% in 2012/2013 to 24% in 2014/2015. This continues the upward trend since 2008/2009 (17%) noted in previous Scottish Health Survey reports ^[26] . There was a significant increase from 2008/2009 to 2014/2015 in the proportion of both men (13% to 20%) and women (22% to 29%) reporting at least one symptom of anxiety.

Table 1.5

1.4.4 Symptoms of anxiety in 2012-2015 (combined), by age and sex, and by area deprivation

Prevalence of two or more symptoms of anxiety was lowest for those aged 75 and over (5% compared to 9-13% for other age groups). A similar pattern of lower prevalence among the older age groups was seen both for men (4-5% for those aged 65 and over) and women (5% for those aged 75 and over). The overall proportion with at least one symptom of anxiety also tended to decline with age, with levels at 28% among those aged 16-24 and 13% among those aged 75 and over.

Table 1.6

There were differences in the prevalence of anxiety according to area deprivation, with those in the most deprived areas being about twice as likely as those in the least deprived to report at least two symptoms (15% compared with 7%, using age-standardised figures). There was a similar pattern for those with one or more symptoms (29% compared with 17%). This pattern was similar for men and women.

Table 1.7

1.5 Suicide Attempts

1.5.1 Trends in suicide attempts since 2008/2009 (combined), by sex

The proportion of adults who self-reported to have ever attempted suicide was 6% in 2014/2015. Levels of self-reported suicide attempts were similar for men (5%) and women 7% with neither showing a significant change from 2008/2009 (3% and 6% respectively).

Table 1.5

1.5.2 Suicide attempts in 2012-2015 (combined), by age and sex, and by area deprivation

For all adults, those in the oldest age groups were less likely than younger age groups to say they had ever attempted suicide (1-2% for those aged 65 and over compared with 6-8% for those aged 16-54). A similar pattern was seen for both men and women.

Table 1.6

Using age-standardised data for 2012-2015 combined, adults living in the most deprived areas were more likely than those in less deprived areas to have attempted to take their own life (10% in the most deprived quintile compared with 3-4% of those in the three least deprived quintiles). The same pattern was seen for both men and women, with those in the most deprived areas being the most likely to have ever attempted to take their own life (9% for men, 12% for women).

Table 1.7

1.6 Deliberate Self-Harm

1.6.1 Trends in self-reported self-harm since 2008/2009 (combined), by sex

In 2014/2015 combined, 7% of adults said they had ever deliberately self-harmed. This represents a significant increase compared with levels reported in 2012/2013 (5%) and in earlier years of the survey (2% in 2010/2011, 3% in 2008/2009). Significantly more women (9%) than men (6%) reported they had ever self-harmed in 2014/2015, with the figure for women being a significant increase from that seen in 2012/2013 (6%), 2010/2011 (3%) and 2008/2009 (4%). For men, the 2014/2015 figure of 6% was significantly higher than that seen in either 2008/2009 or 2010/2011 (2% in both periods) but not than that in 2012/2013 (4%). As noted earlier, comparisons with prevalence before 2012 should be interpreted with caution.

Table 1.5

1.6.2 Self-harm in 2012-2015 (combined), by age and sex, and by area deprivation

The proportion of adults who reported to have ever self-harmed was higher for those aged 16-24 (18%), than for older age groups (8% of those aged 25-44, 4% of those aged 45-54, and 0-2% of those aged 55 and over).

Differences between men and women were particularly evident among the youngest age group, with 23% of women in the 16-24 age group reporting they had ever self-harmed, compared with 13% of men in this age group.

Figure 1C, Table 1.6

Age-standardised self-reported prevalence of self-harm varied by level of area deprivation, with no clear pattern. Table 1.7

1.7 Strengths And Difficulties Questionnaire

1.7.1 Trends in children's SDQ scores, 2003 to 2014/2015 (combined), by sex

The proportion of children aged 4-12 who had a borderline or abnormal total difficulties score decreased between 2003 (17%) and 2008/2009 (14%), and stayed at an identical level of 14% in 2010/2011, 2012/2013 and 2014/2015. A significantly higher proportion of boys (17%) than girls (10%) in 2014/2015 were reported to have such difficulties, with boys also having a significantly higher total difficulties mean score (8.5 compared with 6.7 for girls). The proportion decreased significantly for girls between 2003 (15%) and 2014/2015 (10%), but there was no significant change for boys (19% in 2003 and 17% in 2014/2015). The total difficulties mean score for all children also decreased, from 8.2 in 2003 to 7.7 in 2012/2013 and 2014/2015. There was a significant decrease from 2003 to 2014/2015 among girls (7.8 to 6.7) but not boys (8.6 to 8.5).

Of the separate domains of the strengths and difficulties questionnaire, significant decreases between 2003 and 2014/2015 were seen in the proportion of children aged 4-12 assessed as borderline or abnormal in the conduct problems score (24% to 19%) and in the peer problems score (23% to 19%). There was significant change over the same time period in the proportion of children with borderline or abnormal scores for emotional symptoms (16% in 2003 compared with 14% in 2014/2015) and hyperactivity (19% compared with 20% respectively).

The proportion of children with a borderline or abnormal score for prosocial behaviour remained relatively static across the time period at 8-9% (9% in 2014/2015).

Figure 1D, Table 1.8

1.7.2 Children's SDQ scores in 2012-15 (combined), by age and sex, and by area deprivation

Of the four constituent elements of the total difficulties score, boys were significantly more likely than girls to have a borderline or abnormal score for conduct problems (23% compared with 16%), peer problems (22% compared with 16%) and hyperactivity (25% compared with 12%), with there being no difference in terms of emotional problems (14% compared with 13%). Boys were also significantly more likely to have a borderline or abnormal score for pro-social behaviour (12% compared with 6%).

No age group was significantly different from any other in terms of the proportion with borderline or abnormal total difficulty scores, with these ranging from 12-15% across the age groups from 4-12. While the proportion with borderline or abnormal scores increased with age for emotional symptoms (10% for those aged 4-5 compared with 17% for those aged 10-12) and peer problems (17% and 22% respectively) the proportion with borderline or abnormal hyperactivity scores decreased (22% and 16% respectively). There was no significant difference by age for borderline or abnormal scores for conduct problems or prosocial behaviour.

Boys and girls had similar age-based patterns, with the exception of peer problems. For boys, the level of borderline or abnormal peer problems increased with age from 19% for those aged 4-5 to 24-25% for those aged 8-12, whereas for girls lower levels were seen for those aged 6-10 (12-14%) than those aged either 4-5 (16%) or 10-12 (19%).

Table 1.9

Age-standardised SDQ scores also varied according to level of area deprivation. Borderline or abnormal total difficulties scores were significantly higher for children in the most deprived areas (22%) than their peers in the least deprived areas (6%).

Table 1.10