It’s good to talk… yes?
Stigma is getting a lot of press recently. Celebrities, sportspeople and even the Royals have been busy raising awareness about mental health problems. The received wisdom is that as people understand more about mental illness, they are more likely to seek help from services and to disclose to family and friends.
Anti-stigma campaigns have been found to reduce personal stigma (see David Steele’s Mental Elf Blog for more on self-stigma). Short-term attitudes may also improve in the public (Suzanne Dash talks about this in her Mental Elf blog) but what does that actually mean? Is there any evidence to suggest that increased awareness changes behaviour?
The Time to Change Campaign is a large National anti-stigma campaign targeting attitudes and aiming to reduce discrimination, aimed at middle socioeconomic groups age 25-45. It has run since 2007. The positive effects of Time to Change are described by Thornicroft as “significant and moderate” (Thornicroft et al, 2016). Increases in positive attitudes related to prejudice and exclusion have been found, but no improvement in measures of tolerance and support for community care.
Thornicroft has described evidence for a “dose-effect” relationship between campaign awareness and attitudes. Arguably attitude change is always good (as long as it’s in the right direction!) but what if it doesn’t change help-seeking behaviour; is the campaign then worthwhile? It is expensive (Smith, 2013).
The Attitudes to Mental Illness survey (PDF) has been used as part of the Time to Change evaluation since 2008.
A nationally representative sample of about 1,700 adults living in England have been interviewed annually.
The sample is selected by region and classified by social status. Interviews take place in the interviewees’ own homes.
Since 2012, awareness of the campaign itself has been in included in the evaluation.
For this study interviewees were asked:
- If you had a mental illness, how likely would you be to go to your GP for help? (5 point scale)
- How comfortable would you be talking to friend or family member? (7 point scale)
- Who is the person closest to you with some kind of mental illness?
- Socioeconomic status
- They were shown a card with social marketing material from the campaign and asked if they had seen them before.
Gender, age and ethnicity were allowed for in the analysis of the results.
Awareness of the campaign was generally between 20 to 30%, although there was a peak in 2013 of 43.3%.
|Aware of Time to Change||Unaware of Time to Change||Increased likelihood of help seeking if you recognised the campaign (Odds Ratio with 95% Confidence Interval)|
|Tell employer about mental health problems||39%||35%||1.20 (95% CI 1.06 to 1.35)|
|Tell family and friends about mental health problems||73%||67%||1.27 (95% CI 1.14 to 1.43)|
|Talk to your GP about mental health problems||84%||81%||1.18 (95% CI 1.03 to 1.36)|
In 2016 there was a dip in intention to seek help from the GP; the authors speculate this being because of increasing austerity.
Women and people from higher socioeconomic groups were less likely to go to their employer and women were more likely to speak to friends and family than men were.
People aware of the Time to Change campaign were slightly more comfortable disclosing mental health problems to friends and family and said that if they were mentally ill they thought that they would seek help.
Strengths and limitations
This was a large study sample based on a massive campaign and the methodology of the evaluation is robust.
The authors point out, as a limitation, concerns re social desirability with interviewees potentially saying what they think we want to hear.
We also don’t know which disorder people are referring to; “mental disorder” is a broad church.
One thing I wondered about is whether there may be something different about the people who were aware of the Time to Change campaign. Surely they will have also been picking up other stuff in the media, how do we know the campaign made any difference? They might have been more swayed by the musings of Stephen Fry.
Implications for practice
It is difficult to say how much the Time to Change campaign has changed attitudes. We know that for many of our patients the stigma they experience is worse than their illness (Sartorius, 2007). Any change in the right direction must be welcomed.
This paper suggests that there might have been a bit of a change in the direction of more people divulging to friends, family and the GP (or at least thinking you would if you were ill). So that’s good… but what next?
Simon Wessely caused a bit of a fuss recently saying “Every time we have a mental health awareness week my spirits sink, we don’t need people to be more aware. We can’t deal with the ones who already are aware.” (BMJ, 2017)
It’s a good point. I can’t imagine many health professionals whooping with joy at the prospect of more help-seeking patients. We need as a society to treat people with mental health problems better; and that must include providing decent help for them once we have encouraged them to seek it.
Conflicts of interest
Tackling mental-health-related stigma: a narrative review of anti-stigma interventions
Thornicroft G et al. (2016) Evidence for effective interventions to reduce mental-health-related stigma and discrimination. The Lancet 2016;387:1123–32. doi:10.1016/S0140-6736(15)00298-6
Smith M. (2013) Editorial. Anti-stigma campaigns: time to change.
Sartorius, N. (2007) Stigma and Mental Health. Lancet. 2007. 370; 9590, 810–811 DOI: http://dx.doi.org/10.1016/S0140-6736(07)61245-8
Interview: Simon Wessely: “Every time we have a mental health awareness week my spirits sink” http://www.bmj.com/content/358/bmj.j4305.2017.
Simon Wessely: “Every time we have a mental health awareness week my spirits sink” BMJ 2017;358:j4305
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Thanks for this interesting post Aileen. These kind of population-level interventions are notoriously difficult to evaluate. You fairly state that there seems to be (albeit modest) effect on people divulging concerns over their mental health to others, which is positive. Changing cultural norms is like turning a super-tanker after all!
You seem to imply that it is an ‘either-or’ when it comes to more people seeking help OR being able to treat the ones that do present. Surely we should be hoping for ‘both-and’? i.e. more of the people who need help seek it and all those that seek it, receive it.
Glad you found it interesting Ian. Of course in an ideal world we are aiming for both and it would be ridiculous to argue that we shouldn’t aspire to improve attitudes. But I think Simon Wessley is spot on and at the moment we don’t have the luxury of ‘both-and’. This will sound cynical but being well enough to ask for help is practically a contraindication to receiving it!
Seeing mental health stigma more widely discussed is a sign that the issue is being considered by many more people and organisations as something that needs addressing, which is very encouraging as we are far from having done this job.
Aileen’s blog is a welcome part of this current high profile debate, as was Sir Simon Wessley’s recent commentary which led to the piece on Radio 4 ‘All in the Mind’ that aired earlier this week http://www.bbc.co.uk/programmes/b09byv6m
It is also good to see more mental health campaigns and more people sharing their experiences, including MPs, sports and music stars, younger members of the Royal Family, and everyday people in a wide range of communities, as this is something we know influences attitudes. The existence of the TTC campaign since 2007 has helped create a more positive environment and raised a more positive profile for mental health within society.
However a common misconception, and one repeated in Aileen’s piece, is that the purpose of the Time to Change campaign is to change attitudes in order to encourage more help seeking. Our outcomes are to reduce the impact of stigma and discrimination on the lives of the one in four of us with mental health problems – the stigma and discrimination which leads to people losing jobs and friends and being excluded from many everyday aspects of society – and to work with people with mental health experiences and communities to drive that change.
The recent piece in the BJP about the impact of TTC awareness on increased comfort disclosing to friends, family, GPs and employers is only a very small part of the extensive evaluation of our work and our outcomes.
By focusing only on attitudes and help seeking, Aileen’s piece overlooked one of the cornerstones of our evaluation programme, and the area we are more interested in which is actual changed behaviour that leads to reduced levels of discrimination (in England).
The ‘Viewpoint’ survey we commissioned the IOPPN to carry out between 2008 and 2014 was a survey of discrimination reported by approximately 1,000 people each year who had recently been in contact with specialist mental health services. The paper on these findings was published in a special issue of Acta Psychiatrica Scandinavica in 2016 with the conclusion that “discrimination has fallen significantly over 2008–2014”. Average levels of discrimination during this period dropped from 42% to 28% with the most significant decreases in discrimination from family, friends, social life, dating and employment. This has made a profound difference to the lives of many people who are already seeking help http://onlinelibrary.wiley.com/doi/10.1111/acps.12610/abstract
There is still much more to do, but the data over the ten years that Time to Change has been delivered shows sustained improvements in public attitudes (9.6% since 2008) rather than just “short term” improvements. This is a credit to all those who have shared their experiences and those running campaigns locally and nationally.
If we are encouraging more help seeking (as the BJP paper shows) then surely this will help make the case for more resources rather than hide the full extent of need. We wouldn’t be having this argument about help seeking for cancer or heart problems, and we need to encourage earlier help seeking as well as people being able to get the right, non-judgemental support from family, friends, colleagues and managers as well as from the NHS.
It is more important to us that our campaign delivers change in attitudes and discrimination, rather than being a well recognised brand (even though this makes attribution more complex).
Aileen’s final point indicates that we have the same hope for our nation, in that we treat people with respect and dignity and don’t judge and discriminate, and that when people seek help they get the right support, and they get it quickly.
[…] Mental illnesses are associated with a range of adverse outcomes that can seem to jostle for attention from researchers, clinicians, elves and the public. Criminal offending, especially violence, is one that’s been much debated. This has driven research, and a more measured understanding: a range of diagnoses are associated with modest increases in relative risk, more so if substance use disorder is also present (Stevens H et al, 2015; Webb R et al, 2014; Fazel S et al, 2014), but most individuals with mental illness aren’t violent. These subtleties need responsible communication, facing up to the evidence (Mullen P, 2009), but with care not to overstate links, as perceived dangerousness remains a major part of stigma. […]