- Email: [email protected]
Public perceptions of stigma towards people with schizophrenia, depression, and anxiety
Psychiatry Research 220 (2014) 604–608
Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Public perceptions of stigma towards people with schizophrenia, depression, and anxiety$ Lisa Wood a,n, Michele Birtel b, Sarah Alsawy c, Melissa Pyle c, Anthony Morrison b,c a
Inpatient and Acute Directorate, North East London Foundation Trust, Goodmayes Hospital, Essex, IG3 8XJ UK School of Psychological Science, University of Manchester, Oxford Road, Manchester, M13 9PL, UK c Psychosis Research Unit, Greater Manchester West NHS Foundation Trust, Prestwich Hospital, Bury New Road, Manchester, M25 3BL, UK b
art ic l e i nf o
a b s t r a c t
Article history: Received 7 March 2014 Received in revised form 23 June 2014 Accepted 8 July 2014 Available online 15 July 2014
Stigma is one of the greatest challenges facing people with a psychiatric diagnosis. They are widely stigmatised by the general public in the western world. The aim of this study was to examine public stigma attitudes towards schizophrenia, depression and anxiety. The Office of National Statistics (ONS) 2008 opinions survey (n ¼1070) was utilised. Percentage of endorsements for stigma items were initially compared to the previous 1998 and 2003 databases. Overall stigma attitudes had decreased (from 1998 to 2008) but increased since 2003. A principal components factor analysis identified that stigma attitudes have the same three factors structure across all diagnoses; negative stereotypes, patient blame and inability to recover. Schizophrenia was significantly associated with the most negative stereotypes, least blamed and viewed as least likely to recover compared to anxiety and depression. Public and individualised interventions that target diagnostic variability in stigma attitudes need to be developed and examined in future research. & 2014 Published by Elsevier Ireland Ltd.
Keywords: Schizophrenia Depression Anxiety disorder Stigma Public attitudes Survey data
1. Introduction 1.1. Background Stigma was originally defined as an attribute that is deeply discrediting which reduces the person from a whole person to a tainted or discounted one (Goffman, 1963, p. 3). It is widely acknowledged that psychiatric diagnoses are stigmatised and associated with negative public attitudes (Angermeyer and Matschinger, 2003). A breadth of literature has conceptualised stigma in various ways (Link and Phelan, 2001; Corrigan and Watson, 2002; Brohan et al., 2010) but arguably the most influential approach is outlined by Corrigan and Watson (2002) who described stigma as having two major dimensions: public stigma and self-stigma. Public stigma comprises negative attitudes (prejudice), beliefs (stereotypes) and behaviour (discrimination) towards the stigmatised person and self-stigma is the internalisation of these experiences by the stigmatised individual.
☆ The authors recognise that the terms and language used in this paper are not universally endorsed by all. Where differences of opinion arose in this paper, the team decided to use the term that was endorsed by the majority whilst also respecting the views of others. n Corresponding author. E-mail address: [email protected] (L. Wood).
http://dx.doi.org/10.1016/j.psychres.2014.07.012 0165-1781/& 2014 Published by Elsevier Ireland Ltd.
Survey results from 2000 members of the English public identified three dominant stigmatising attitudes towards people with a psychiatric diagnosis; fear and exclusion, irresponsibility and lack of control and benevolence (Brocklington et al., 1993). Crisp et al., (2005, 2000)scrutinised the UK Office of National Statistics (ONS) opinions survey and found that people diagnosed with a mental health problem were most likely to be seen as unpredictable, hard to talk to and unlikely to recover. Similar attitudes have been identified across the western world in places such as Australia, Germany and the USA (e.g. Jorm et al., 1999; Angermeyer and Matschinger, 2003; Silton et al., 2011). A recent review has illustrated that public perceptions of mental health diagnoses vary across the diagnostic categories (Parle, 2012). People diagnosed with schizophrenia are viewed most negatively, and are considered more dangerous and unpredictable compared to other diagnoses (Angermeyer and Matschinger, 2003). Dinos et al. (2004) interviewed 46 people with experiences of mental health difficulties about their experiences of stigma and found that people diagnosed with schizophrenia were more likely than any other group to report overt experiences of stigma such as verbal abuse, physical abuse, loss of contacts, and overt discrimination. Vignette studies also illustrate the strong bias that the public have towards psychiatric diagnoses. Yang et al. (2013) presented college students with a vignette and randomly assigned a diagnosis that described the prodromal symptoms. Schizophrenia elicited more negative stereotypes and
L. Wood et al. / Psychiatry Research 220 (2014) 604–608
psychosis at risk elicited more social distance and less willingness to help compared to other diagnoses. This pattern has been identified in similar studies (Link et al., 1999; Angermeyer and Matschinger, 2003). Public campaigns, which aim to educate the public about mental health and increase social contact, have been shown to reduce stigma. Crispet al. (2000, 2005) study results highlighted a reduction in negative attitudes toward mental illness following the changing minds campaign. The changing mind campaign (Crisp, 2004) ran from 1997 to 2003 and aimed to develop public and professional understanding of mental health problems. A longitudinal study conducted by Mehta et al. (2009), who examined public attitudes towards psychiatric diagnoses, highlighted that there was a positive impact of the UK's changing minds campaign and Scotland's equivalent see me campaign but overall there was still a significant deterioration in public attitudes over time (1994–2003). There is extensive evidence that people who have a mental health diagnosis are viewed negatively by the public with certain diagnoses being viewed more negatively than others. However, there is a need to examine prevailing public attitudes in the UK population. A more recent ONS database has been published (2008) with data following up from two previous studies (Crisp et al., 2000, 2005) allowing for the examination of further change in public attitudes. Examining public attitudes are essential in tackling stigma as these underlie discriminatory behaviour. Crisp and colleagues did not attempt to examine the factor structure of stigmatising attitudes and whether they differ significantly across diagnoses. This would be helpful to explore in order to tailor public stigma campaigns appropriately to specific diagnoses.
1.2. Aim This research aimed to explore public attitudes towards psychiatric diagnoses, namely schizophrenia, depression and anxiety using the UK ONS opinions survey database (ONS, 2008) (National Statistics Opinions Survey, 2008). The main aims of the study were to: 1. Compare stigma attitudes to those found by Crisp et al. (2000, 2005) to examine any changes over time. 2. To conduct a factor analysis in order to determine the factor structure of stigma attitudes and examine them for significant differences across diagnoses.
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2.3. Materials The opinions survey included five modules for respondents to answer, all of which were of multiple choice. These modules were identical to those used in Crisps et al. (2000, 2005) previous studies. Full details of all modules and questions can be found in the ONS opinions survey technical report (ONS, 2008). For the purpose of this study, two modules were examined: 2.3.1. Module 01; CPS Core Respondents were asked sixteen demographics questions which included age, sex, race, marital status, educational attainment and employment. All questions were multiple choice. 2.3.2. Module M208; Stigma This module included questions about attitudes towards psychiatric diagnoses. Respondents were requested to rate their attitudes towards each of the following diagnoses: severe depression, anxiety, schizophrenia, dementia, eating disorder, alcoholism, and drug addiction. They were asked to rate eight individual statements about each diagnostic category: danger to others, unpredictable, hard to talk with, have only themselves to blame for their condition, would not improve if given treatment, feel different from the way we feel at times, could pull themselves together if they wanted, and will never recover fully. Each item was rated on a five-point scale of extremes from positive to negative, for example: would improve if given treatment – would not improve if given treatment. Respondents were not asked whether they had experienced a mental health problem themselves. For the purpose of this study, only the rating scales of schizophrenia, depression and anxiety were used. 2.4. Statistical analysis The 2008 database was downloaded by authors from the ONS website in June 2013 (ONS, 2008). The previous two databases used by Crisp et al. (2000, 2005) were no longer available for download. The Statistical Package for the Social Sciences (SPSS) version 18 (SPSS, 2010) was used to conduct all data analysis. Data was reversed to ensure higher scores representing the most negative attitudes. All data were found to be normally distributed. Initially, endorsement percentages for the eight stigma items for each diagnostic category were compared to the previous two ONS databases, 1998 and 2003 (Crisp et al., 2000,2005). Negative endorsements were calculated as outlined by Crisp et al. (2000). The stigma attitudes questionnaire was then subjected to a principal components factor analysis and a Direct Oblimin rotation for schizophrenia, depression and anxiety respectively. Direct Oblimin rotation was chosen because it is likely that the factors identified are going to be related (Field, 2009). The number of factors extracted were those with eigen values greater than one. The scree plot was also inspected to identify factors (Coolican, 2009). Factor loading values were taken as significant over 0.4 as recommended (Field, 2009). The factors identified were then entered into independent one-way Analysis of Variance (ANOVA) models. The extracted factors were entered as independent variables and the diagnostic subtype as the dependent variables.
3. Results 3.1. Sample demographics
2. Method 2.1. Participants For the Office of National Statistics (ONS) opinions survey (July 2008), the sample was identified through multi-stage stratified random sampling. 1792 households were initially identified as eligible to take part in the survey. The households were identified using the Postcode Addresses File of the ONS. Full details of sampling methods can be found in the ONS opinions survey technical report (ONS, 2008). Sampling methods were consistent across the previous two studies (Crisp et al. 2000, 2005). From the total households contacted, 524 (29%) refused to take part in an interview, 192 (11%) were not contactable and 6 (0%) were of unknown eligibility. In total 1070 (60%) of households had an individual who took part in the interview.
2.2. Procedure The opinions survey comprised face-to-face interviews conducted by interviewers trained on the administered measures. The interviews took an estimated 25min to complete per respondent. The interviewer made at least three calls to an address before they are coded as a non-contact. After the field period, a proportion of non-contacts and refusals were attempted to be contact by the telephone unit.
Interviews were obtained with 1064 people aged 16 years and over. This response rate of 60% is slightly lower than that in Crisps et al.'s (2000) (65%) and Crisps et al. (2005) (67%) papers. The average age of the sample was 50.95 (16–94; S.D. 18.85). Participant demographics can be seen in Table 1. These demographics are similar to those identified in Crisps et al. (2000) study (45% males, 24% singles and 95% white). Their 2005 study does not report participant demographics. 3.2. Opinions of people with mental illness Percentages of public agreement with the negative stigma statements were compared to the 1998 and 2003 findings of Crisp et al. (2000, 2005), results can be seen in Table 2. Broadly, the results for the 2008 database follow the same trend as the previous two databases. Schizophrenia's items of dangerous to others, unpredictable and hard to talk to have all continued to decrease over time. Interestingly, selves to blame, not improved if treated and feel different from us had previously lowered in 2003
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L. Wood et al. / Psychiatry Research 220 (2014) 604–608
but increased back to similar levels in the original database in 1998. For depression, dangerousness to others had increased and, similarly to schizophrenia, items relating to self-blame, them being different and recovery had increased since 2003. For anxiety, overall negative views had decreased except for items relating to recovery which were both higher than that found in the initial 1998 database. Since 1998, negative attitudes have broadly improved excluding perceived ability to recovery which has deteriorated. 3.3. Initial factor analyses All three stigma questionnaires were then subject to a factor analysis in order to indentify the factor structure of stigma attitudes. Factors extracted were based on screening the scree plots, explained variance and eigen values (Table 3). All three scales had the same factor structure (Table 4). Factor 1 can be seen as the negative stereotypes, factor two can be identified as patient blame, and factor three can be described as the inability to recover. It can be seen that the factor which explained the most variance for schizophrenia was negative stereotypes indicating that this factor is most representative of public views of schizophrenia whilst patient blame was most associated with depression and anxiety respectively. The factor loadings in Table 4 indicate that dangerous to others, unpredictable and hard to talk with loaded highest on the schizophrenia factor, with depression and anxiety loading less highly. This was also the same for patient blame. Factor three loadings were highest for schizophrenia indicating that people view that as the difficult that people are least likely to recover from. 3.4. One way analysis of variance of factors From the factor analysis, individual subscales were created and compared using three one-way ANOVAs. Negative stereotypes, patient blame and inability to recover were entered as independent variables and schizophrenia, depression and anxiety were entered as dependent variables. Initial descriptives can be seen in Table 5. A number of one way ANOVA's were conducted on the subscale totals. There was a significant between groups effect for negative stereotypes (F (2, 2926) ¼375.499, po 0.001), patient blame (F (2, 2919) ¼51.048, po 0.0001), and inability to recover (F (2, 2931) ¼
Table 1 Sample demographics. Demographic
N (Percentage)
Gender Male Female Marital status Single Married Separated/Divorced Widowed Ethnicity White Asian Black Other Employment status Employed Economically inactive Unemployed
511 (48%) 553 (52%) 278 (26%) 502 161 123 975
(47%) (15%) (12%) (91%)
49 20 20 578
(5%) (2%) (2%) (54%)
446 (42%) 40 (4%)
Table 2 Percentage agreeing with negative statements in 1998, 2003 and 2008.
Danger to others Unpredictable Hard to talk to Selves to blame Not improved if treated Feel different from us Could pull self together Never fully recover
Schizophrenia
Depression
Anxiety
98
3
8
98
3
8
98
3
8
71 77 58 8 15 57 8 51
66 73 52 6 12 37 8 42
63 70 50 9 15 54 10 44
23 56 62 13 16 43 19 23
19 53 56 11 15 30 17 25
21 50 53 14 18 40 17 26
26 50 33 11 14 39 22 22
23 50 26 10 15 25 20 21
20 43 24 10 18 38 18 24
Table 3 Eigen values, individual and total variance explained for rotated factor solutions for schizophrenia, depression and anxiety.
Factor 1: Negative stereotypes Factor 2: Patient blame Factor 3: Inability to recovery Total variance explained
Schizophrenia
Depression
Anxiety
EV ¼2.44 V ¼ 30.41% EV ¼2.03 V ¼ 25.44% EV ¼1.035 V ¼ 12.94% 68.79%
EV ¼1.47 V¼ 18.09% EV ¼1.89 V¼ 23.56% EV ¼ 1.23 V¼ 15.33% 56.98%
EV ¼ 2.04 V ¼ 25.55% EV ¼ 1.40 V ¼ 17.50% EV ¼ 1.30 V ¼ 16.23% 59.28%
EV¼ Eigen value, V ¼ Variance explained.
51.048, p o0.001). Bonferroni post hoc analyses were conducted to indentify the significant differences between groups for each individual factor. For negative stereotypes, schizophrenia was significantly higher than depression (0.001) and anxiety (0.001), depression was significantly higher than anxiety (0.001), for patient blame schizophrenia was significantly lower than depression (0.001) and anxiety (0.001) and no difference was found between depression and anxiety (1.000), and for inability to recovery schizophrenia scored significantly higher than depression (0.001) and anxiety (0.001) and no difference was found between depression and anxiety (1.000).
4. Discussion This study aimed to examine the differences in public perceptions of different psychiatric diagnoses and compare public stigma attitudes towards schizophrenia, depression and anxiety. Data was taken from the ONS (2008) opinions survey which examined people's attitudes towards psychiatric diagnoses. Results were compared to Crisp et al. (2000, 2005) previous analyses and the general trend was that negative stigma views had improved slightly since 1998 across all diagnoses. The changing minds campaign, which observed between 1997 and 2003, had a positive impact on negative attitudes towards psychiatric diagnoses given the overall reduction in negative views in 2003. However, it appears that since this campaign ceased views have increased to comparable levels, albeit lower, of that identified in 1998. Public stigma campaigns which promote a positive perception of psychiatric diagnoses should therefore be continued on a long-term basis. For example, Time to change, a continuing UK public stigma campaign which aims to ‘inspire people to work together to end the discrimination surrounding mental health’ should be continued and long-standing. Its priorities are to reduce stigma through social contact and public education. Recent, evaluation of the efficacy of the campaign illustrated that
L. Wood et al. / Psychiatry Research 220 (2014) 604–608
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Table 4 Rotated solution factor loadings for schizophrenia, depression and anxiety. Item
a. Danger to others b. Unpredictable c. Hard to talk to d. Selves to blame e. Not improved if treated f. Feel different from us g. Could pull self together h. Never fully recover
Factor 1: Negative stereotypes
Factor 2: Patient blame
Factor 3: Inability to recover
S
D
A
S
D
A
S
D
A
0.864 0.874 0.790 … … … … …
0.549 0.807 0.729 … … … … …
0.662 0.726 0.752 … … … … …
… … … 0.801 … 0.738 0.812 …
… … … 0.792 … 0.509 0.735 ….
… … … 0.718 … 0.616 0.783 …
… … … … 0.820 … … 0.648
… … … … 0.736 … … 0.728
… … … … 0.822 … … 0.750
S¼ Schizophrenia, D¼ Depression, A ¼Anxiety.
Table 5 Means and standard deviations of individual items and subscales for schizophrenia, depression and anxiety.
Factor 1: Negative stereotypes a. Danger to others b. Unpredictable c. Hard to talk to Factor 2: Patient blame d. Selves to blame f. Feel different to us (reversed) g. Could pull self together Factor 3: Inability to recover e. Not improve if treated h. Never fully recover
Schizophrenia
Depression
Anxiety
11.78 3.93 4.19 3.66 6.55 2.09 2.22 2.24 5.97 2.47 3.50
9.58 2.53 3.52 3.52 7.56 2.31 2.67 2.58 5.30 2.38 2.92
8.61 2.43 3.28 2.90 7.56 2.14 2.73 2.69 5.35 2.48 2.87
(2.75) (1.13) (1.08) (1.03) (2.70) (1.14) (1.15) (1.09) (1.67) (1.16) (1.05)
(2.49) (1.25) (1.13) (1.14) (2.40) (1.20) (1.14) (1.11) (1.89) (1.26) (1.13)
(2.57) (1.26) (1.20) (1.10) (2.47) (1.09) (1.17) (1.05) (1.87) (1.17) (1.11)
people who have mental health difficulties have experienced less stigma and discrimination since the campaign began (Time to Change, 2010). Three identical stigma factors emerged for each diagnosis which reflected themes identified in previous literature (Brocklington et al., 1993). This factor structure suggests that the same attitudes are important across all diagnoses and key to understanding public perceptions. Schizophrenia was viewed significantly more negatively than depression or anxiety in line with previous evidence (Angermeyer and Matschinger, 2003; Crisp et al., 2000, 2005). People diagnosed with schizophrenia are seen as more dangerous and less likely to recover than other diagnoses. Anxiety was seen most favourably by the public; it was associated with less negative stereotypes and seen as more likely to recover. Interestingly, anxiety and depression were seen almost identically for patient blame and incurred more blame than schizophrenia. Depression was associated with more negative stereotypes than anxiety which supports previous literature outlining that people who experience depression are viewed as lazy and not easy to talk to (Thornicroft et al., 2007). A previous review of the stigma literature has illustrated that negative public attitudes towards psychiatric diagnoses stem from perceptions that there is a biogenetic cause of the mental health problem (Lincoln et al., 2008). This may explain why negative perceptions of schizophrenia, depression and anxiety have reduced and patient blame and the inability to recover continue to increase. A way of tackling negative public attitudes is to promote psychosocial alternatives which move away from a biological cause which may seem more permanent. In a recent consensus study by Clement et al. (2010), recovery-orientated views (i.e. that recovery in psychosis is possible and achievable) and seeing the person (i.e. seeing the person not the diagnosis) were the most important messages to include in a public stigma
campaign. These messages are extremely likely to reduce all three negative perspectives identified in this study. This research also highlights the need to support people with mental health diagnoses, particularly schizophrenia, in coming to terms with the negative public attitudes towards psychiatric diagnoses. As outlined, stigma can be internalised and have a number of detrimental impacts on the individual, for example reduce self-esteem, cause depression and anxiety and impede recovery (Link et al., 2001). Arguably, because internalised stigma refers to an individual's negative beliefs about themselves, a Cognitive Behavioural Therapy (CBT) approach may be best placed to approach these issues and is recommended by National Institute of Clinical Excellence guidelines (NICE, 2009). Public attitudes of stigma and their impacts, if relevant to an individual's difficulties, should be made clear within an individual CBT formulation which will facilitate the use of important change mechanisms and facilitate recovery, for example, understanding the impacts of diagnosis, normalisation, positive data logs, evaluating the accuracy of internalised stereotypes, and understand the impacts of stigma upon core beliefs.
4.1. Strengths and limitations A strength of this study was the use of a large scale public database which facilitated examination of public attitudes in a representative sample. The attitudes shared within this sample are likely to be more reflective of the general population due to the large sample size. This study also suffered from typical limitations of large scale databases. The response rate was 60%, slightly lower than the previous two studies (Crisp et al., 2000, 2005), but close to the expected response rate for population survey studies. A lower response rate can risk sampling bias and threaten the accuracy of results. Moreover, the database comprised secondary data with pre-defined variables, restricting the scope of exploration for stigma. Questions were limited to eight five-point likert scale responses per diagnostic category. Further studies would benefit from examining attitudes in more detail and examining the public's perceived causes of the diagnoses to understand the relationship in more detail (Read and Harre, 2001).
4.2. Conclusion Negative public attitudes towards psychiatric diagnoses are still prevalent with schizophrenia being viewed most negatively by the public. Public campaigns such as changing minds was shown to have positive impacts on public attitudes toward mental health, however these changes were not long-lasting. Stigma campaigns need to be long-standing in order for sustained change to occur.
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Declaration of interests None. References Angermeyer, M.C., Matschinger, H., 2003. Public beliefs about schizophrenia and depression: similarities and differences. Social Psychiatry and Psychiatric Epidemiology 38, 526–534. Brocklington, I.F., Hall, P., Levings, J., Murphy, C., 1993. The community's tolerance of the mentally ill. British Journal of Psychiatry 162, 93–99. Brohan, E., Slade, M., Clement, S., Thornicroft, G., 2010. Experiences of mental illness stigma, prejudice and discrimination: a review of measures. British Medical Council Health Services Research 10, 1–11. Clement, S., Jarrett, M., Henderson, C., Thornicroft, G., 2010. Messages to use in population-level campaigns to reduce mental health-related stigma: consensus development study. Epidemiologia e Psichiatria Sociale 19, 72–79. Coolican, H., 2009. Research Methods and Statistics in Psychology. Routledge, London. Corrigan, P., Watson, A., 2002. The paradox of self-stigma and mental illness. Clinical Psychology: Science and Practice 9, 35–53. Crisp, A.H., 2004. Introduction to the Royal College of Psychiatrists campaign. In: Crisp, AH (Ed.), Every family in the land: understanding prejudice and discrimination against people with mental illness, 2004. Royal Society of Medicine Press, London, pp. 380–383. Crisp, A.H., Gelder, M.G., Goddard, E., Meltzer, H., 2005. Stigmatizaiton of people with mental illnesses: a follow-up study within the Changing Minds Campaign of the Royal College of Psychiatrists. World Psychiatry 4 (2), 106–113. Crisp, A.H., Gelder, M.G., Rix, S., Meltzer, H.I., Rowlands, O.J., 2000. Stigmatisation of people with mental illness. British Journal of Psychiatry 177, 4–7. Dinos, S., Stevens, S., Serfaty, M., Weich, S., King, M., 2004. Stigma: the feelings and experiences of 46 people with mental illness. British Journal of Psychiatry 184, 176–181. Field, A., 2009. Discovery Statistics using SPSS. Sage Publications, London. Goffman, E., 1963. Stigma: Notes on the Management of Spoiled Identity. Penguin Books, Harmondsworth, Middlesex. Jorm, A.F., Korten, A.E., Jacomb, P.A., Chistensen, H., Henderson, S., 1999. Attitudes towards people with a mental disorder: a survey of the Australian public and health professionals. Australian and New Zealand Journal of Psychiatry 33, 77–83.
Lincoln, T.M., Arens, E., Berger, C., Rief, W., 2008. Can antistigma campaigns be improved? A test of the impact of biogenetic vs psychosocial causal explanations on implicit and explicit attitudes to schizophrenia. Schizophrenia Bulletin 34 (5), 984–994. Link, B.G., Phelan, J.C., Bresnahan, M., Stueve, A., Pescosolido, B.A., 1999. Public conceptions of mental illness: labels, causes, dangerousness, and social distance. American Journal of Public Health 89, 1328–1333. Link, B.G., Phelan, J.C., 2001. Conceptualising stigma. Annual Review of Sociology 27, 363–385. Link, B.G., Struening, E.L., Neese-Todd, S., Asmussen, S., Phelan, J.C., 2001. Stigma as a barrier to recovery: the consequences of stigma for the self-esteem of people with mental illness. Psychiatric Services 52, 1621–1626. Mehta, N., Kassam, A., Leese, M., Butler, G., Thornicroft, G., 2009. Public attitudes towards people with mental illness in England and Scotland, 1994–2003. The British Journal of Psychiatry 194, 278–284. NICE, 2009. Core interventions in the treatment and management of Schizophrenia in primary and secondary care. NICE, London. Office for National Statistics. Social and Vital Statistics Division, ONS Opinions Survey, July 2008 [computer file]. Colchester, Essex: UK Data Archive [distributor], July 2011. SN: 6797, http://dx.doi.org/10.5255/UKDA-SN-6797-1; Silton, N., Flannelly, K., Milstein, G., Vaaler, M., 2011. Stigma in America: has anything changed? impact of perceptions of mental illness and dangerousness on the desire for social distance: 1996 and 2006. Journal of Nervous & Mental Disease 199, 361–366. Parle, S., 2012. How does stigma affect people with mental illness? Nursing Times 108 (28), 12–14. Read, J., Harre, N., 2001. The role of biological and genetic causal beliefs in the stigmatisation of ‘mental patients’. Journal of Mental Health 10, 223–235. SPSS, 2010. Statistical Package for the Social Sciences. IBM, USA (Version 18). Silton, N., Flannelly, K., Milstein, G., Vaaler, M., 2011. Stigma in America: Has Anything Changed?: Impact of Perceptions of Mental Illness and Dangerousness on the Desire for Social Distance: 1996 and 2006. Journal of Nervous & Mental Disease 119 (6), 361–366. Thornicroft, G., Rose, D., Kassam, A., 2007. Discrimination in health care against people with mental illness. International Review of Psychiatry 19 (2), 113–122. Time to Change, 2010. Children and Young People's Programme Development. Rethink Mental Illness, London. Yang, L.H., Anglin, D.M., Wonpat-Borja, A.J., Opler, M.G., Greenspoon, M., Corcoran, C.M., 2013. Public stigma associated with psychosis risk syndrome in a college population: implications for peer intervention. Psychiatry Services 64, 284–288.
Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Public perceptions of stigma towards people with schizophrenia, depression, and anxiety$ Lisa Wood a,n, Michele Birtel b, Sarah Alsawy c, Melissa Pyle c, Anthony Morrison b,c a
Inpatient and Acute Directorate, North East London Foundation Trust, Goodmayes Hospital, Essex, IG3 8XJ UK School of Psychological Science, University of Manchester, Oxford Road, Manchester, M13 9PL, UK c Psychosis Research Unit, Greater Manchester West NHS Foundation Trust, Prestwich Hospital, Bury New Road, Manchester, M25 3BL, UK b
art ic l e i nf o
a b s t r a c t
Article history: Received 7 March 2014 Received in revised form 23 June 2014 Accepted 8 July 2014 Available online 15 July 2014
Stigma is one of the greatest challenges facing people with a psychiatric diagnosis. They are widely stigmatised by the general public in the western world. The aim of this study was to examine public stigma attitudes towards schizophrenia, depression and anxiety. The Office of National Statistics (ONS) 2008 opinions survey (n ¼1070) was utilised. Percentage of endorsements for stigma items were initially compared to the previous 1998 and 2003 databases. Overall stigma attitudes had decreased (from 1998 to 2008) but increased since 2003. A principal components factor analysis identified that stigma attitudes have the same three factors structure across all diagnoses; negative stereotypes, patient blame and inability to recover. Schizophrenia was significantly associated with the most negative stereotypes, least blamed and viewed as least likely to recover compared to anxiety and depression. Public and individualised interventions that target diagnostic variability in stigma attitudes need to be developed and examined in future research. & 2014 Published by Elsevier Ireland Ltd.
Keywords: Schizophrenia Depression Anxiety disorder Stigma Public attitudes Survey data
1. Introduction 1.1. Background Stigma was originally defined as an attribute that is deeply discrediting which reduces the person from a whole person to a tainted or discounted one (Goffman, 1963, p. 3). It is widely acknowledged that psychiatric diagnoses are stigmatised and associated with negative public attitudes (Angermeyer and Matschinger, 2003). A breadth of literature has conceptualised stigma in various ways (Link and Phelan, 2001; Corrigan and Watson, 2002; Brohan et al., 2010) but arguably the most influential approach is outlined by Corrigan and Watson (2002) who described stigma as having two major dimensions: public stigma and self-stigma. Public stigma comprises negative attitudes (prejudice), beliefs (stereotypes) and behaviour (discrimination) towards the stigmatised person and self-stigma is the internalisation of these experiences by the stigmatised individual.
☆ The authors recognise that the terms and language used in this paper are not universally endorsed by all. Where differences of opinion arose in this paper, the team decided to use the term that was endorsed by the majority whilst also respecting the views of others. n Corresponding author. E-mail address: [email protected] (L. Wood).
http://dx.doi.org/10.1016/j.psychres.2014.07.012 0165-1781/& 2014 Published by Elsevier Ireland Ltd.
Survey results from 2000 members of the English public identified three dominant stigmatising attitudes towards people with a psychiatric diagnosis; fear and exclusion, irresponsibility and lack of control and benevolence (Brocklington et al., 1993). Crisp et al., (2005, 2000)scrutinised the UK Office of National Statistics (ONS) opinions survey and found that people diagnosed with a mental health problem were most likely to be seen as unpredictable, hard to talk to and unlikely to recover. Similar attitudes have been identified across the western world in places such as Australia, Germany and the USA (e.g. Jorm et al., 1999; Angermeyer and Matschinger, 2003; Silton et al., 2011). A recent review has illustrated that public perceptions of mental health diagnoses vary across the diagnostic categories (Parle, 2012). People diagnosed with schizophrenia are viewed most negatively, and are considered more dangerous and unpredictable compared to other diagnoses (Angermeyer and Matschinger, 2003). Dinos et al. (2004) interviewed 46 people with experiences of mental health difficulties about their experiences of stigma and found that people diagnosed with schizophrenia were more likely than any other group to report overt experiences of stigma such as verbal abuse, physical abuse, loss of contacts, and overt discrimination. Vignette studies also illustrate the strong bias that the public have towards psychiatric diagnoses. Yang et al. (2013) presented college students with a vignette and randomly assigned a diagnosis that described the prodromal symptoms. Schizophrenia elicited more negative stereotypes and
L. Wood et al. / Psychiatry Research 220 (2014) 604–608
psychosis at risk elicited more social distance and less willingness to help compared to other diagnoses. This pattern has been identified in similar studies (Link et al., 1999; Angermeyer and Matschinger, 2003). Public campaigns, which aim to educate the public about mental health and increase social contact, have been shown to reduce stigma. Crispet al. (2000, 2005) study results highlighted a reduction in negative attitudes toward mental illness following the changing minds campaign. The changing mind campaign (Crisp, 2004) ran from 1997 to 2003 and aimed to develop public and professional understanding of mental health problems. A longitudinal study conducted by Mehta et al. (2009), who examined public attitudes towards psychiatric diagnoses, highlighted that there was a positive impact of the UK's changing minds campaign and Scotland's equivalent see me campaign but overall there was still a significant deterioration in public attitudes over time (1994–2003). There is extensive evidence that people who have a mental health diagnosis are viewed negatively by the public with certain diagnoses being viewed more negatively than others. However, there is a need to examine prevailing public attitudes in the UK population. A more recent ONS database has been published (2008) with data following up from two previous studies (Crisp et al., 2000, 2005) allowing for the examination of further change in public attitudes. Examining public attitudes are essential in tackling stigma as these underlie discriminatory behaviour. Crisp and colleagues did not attempt to examine the factor structure of stigmatising attitudes and whether they differ significantly across diagnoses. This would be helpful to explore in order to tailor public stigma campaigns appropriately to specific diagnoses.
1.2. Aim This research aimed to explore public attitudes towards psychiatric diagnoses, namely schizophrenia, depression and anxiety using the UK ONS opinions survey database (ONS, 2008) (National Statistics Opinions Survey, 2008). The main aims of the study were to: 1. Compare stigma attitudes to those found by Crisp et al. (2000, 2005) to examine any changes over time. 2. To conduct a factor analysis in order to determine the factor structure of stigma attitudes and examine them for significant differences across diagnoses.
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2.3. Materials The opinions survey included five modules for respondents to answer, all of which were of multiple choice. These modules were identical to those used in Crisps et al. (2000, 2005) previous studies. Full details of all modules and questions can be found in the ONS opinions survey technical report (ONS, 2008). For the purpose of this study, two modules were examined: 2.3.1. Module 01; CPS Core Respondents were asked sixteen demographics questions which included age, sex, race, marital status, educational attainment and employment. All questions were multiple choice. 2.3.2. Module M208; Stigma This module included questions about attitudes towards psychiatric diagnoses. Respondents were requested to rate their attitudes towards each of the following diagnoses: severe depression, anxiety, schizophrenia, dementia, eating disorder, alcoholism, and drug addiction. They were asked to rate eight individual statements about each diagnostic category: danger to others, unpredictable, hard to talk with, have only themselves to blame for their condition, would not improve if given treatment, feel different from the way we feel at times, could pull themselves together if they wanted, and will never recover fully. Each item was rated on a five-point scale of extremes from positive to negative, for example: would improve if given treatment – would not improve if given treatment. Respondents were not asked whether they had experienced a mental health problem themselves. For the purpose of this study, only the rating scales of schizophrenia, depression and anxiety were used. 2.4. Statistical analysis The 2008 database was downloaded by authors from the ONS website in June 2013 (ONS, 2008). The previous two databases used by Crisp et al. (2000, 2005) were no longer available for download. The Statistical Package for the Social Sciences (SPSS) version 18 (SPSS, 2010) was used to conduct all data analysis. Data was reversed to ensure higher scores representing the most negative attitudes. All data were found to be normally distributed. Initially, endorsement percentages for the eight stigma items for each diagnostic category were compared to the previous two ONS databases, 1998 and 2003 (Crisp et al., 2000,2005). Negative endorsements were calculated as outlined by Crisp et al. (2000). The stigma attitudes questionnaire was then subjected to a principal components factor analysis and a Direct Oblimin rotation for schizophrenia, depression and anxiety respectively. Direct Oblimin rotation was chosen because it is likely that the factors identified are going to be related (Field, 2009). The number of factors extracted were those with eigen values greater than one. The scree plot was also inspected to identify factors (Coolican, 2009). Factor loading values were taken as significant over 0.4 as recommended (Field, 2009). The factors identified were then entered into independent one-way Analysis of Variance (ANOVA) models. The extracted factors were entered as independent variables and the diagnostic subtype as the dependent variables.
3. Results 3.1. Sample demographics
2. Method 2.1. Participants For the Office of National Statistics (ONS) opinions survey (July 2008), the sample was identified through multi-stage stratified random sampling. 1792 households were initially identified as eligible to take part in the survey. The households were identified using the Postcode Addresses File of the ONS. Full details of sampling methods can be found in the ONS opinions survey technical report (ONS, 2008). Sampling methods were consistent across the previous two studies (Crisp et al. 2000, 2005). From the total households contacted, 524 (29%) refused to take part in an interview, 192 (11%) were not contactable and 6 (0%) were of unknown eligibility. In total 1070 (60%) of households had an individual who took part in the interview.
2.2. Procedure The opinions survey comprised face-to-face interviews conducted by interviewers trained on the administered measures. The interviews took an estimated 25min to complete per respondent. The interviewer made at least three calls to an address before they are coded as a non-contact. After the field period, a proportion of non-contacts and refusals were attempted to be contact by the telephone unit.
Interviews were obtained with 1064 people aged 16 years and over. This response rate of 60% is slightly lower than that in Crisps et al.'s (2000) (65%) and Crisps et al. (2005) (67%) papers. The average age of the sample was 50.95 (16–94; S.D. 18.85). Participant demographics can be seen in Table 1. These demographics are similar to those identified in Crisps et al. (2000) study (45% males, 24% singles and 95% white). Their 2005 study does not report participant demographics. 3.2. Opinions of people with mental illness Percentages of public agreement with the negative stigma statements were compared to the 1998 and 2003 findings of Crisp et al. (2000, 2005), results can be seen in Table 2. Broadly, the results for the 2008 database follow the same trend as the previous two databases. Schizophrenia's items of dangerous to others, unpredictable and hard to talk to have all continued to decrease over time. Interestingly, selves to blame, not improved if treated and feel different from us had previously lowered in 2003
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but increased back to similar levels in the original database in 1998. For depression, dangerousness to others had increased and, similarly to schizophrenia, items relating to self-blame, them being different and recovery had increased since 2003. For anxiety, overall negative views had decreased except for items relating to recovery which were both higher than that found in the initial 1998 database. Since 1998, negative attitudes have broadly improved excluding perceived ability to recovery which has deteriorated. 3.3. Initial factor analyses All three stigma questionnaires were then subject to a factor analysis in order to indentify the factor structure of stigma attitudes. Factors extracted were based on screening the scree plots, explained variance and eigen values (Table 3). All three scales had the same factor structure (Table 4). Factor 1 can be seen as the negative stereotypes, factor two can be identified as patient blame, and factor three can be described as the inability to recover. It can be seen that the factor which explained the most variance for schizophrenia was negative stereotypes indicating that this factor is most representative of public views of schizophrenia whilst patient blame was most associated with depression and anxiety respectively. The factor loadings in Table 4 indicate that dangerous to others, unpredictable and hard to talk with loaded highest on the schizophrenia factor, with depression and anxiety loading less highly. This was also the same for patient blame. Factor three loadings were highest for schizophrenia indicating that people view that as the difficult that people are least likely to recover from. 3.4. One way analysis of variance of factors From the factor analysis, individual subscales were created and compared using three one-way ANOVAs. Negative stereotypes, patient blame and inability to recover were entered as independent variables and schizophrenia, depression and anxiety were entered as dependent variables. Initial descriptives can be seen in Table 5. A number of one way ANOVA's were conducted on the subscale totals. There was a significant between groups effect for negative stereotypes (F (2, 2926) ¼375.499, po 0.001), patient blame (F (2, 2919) ¼51.048, po 0.0001), and inability to recover (F (2, 2931) ¼
Table 1 Sample demographics. Demographic
N (Percentage)
Gender Male Female Marital status Single Married Separated/Divorced Widowed Ethnicity White Asian Black Other Employment status Employed Economically inactive Unemployed
511 (48%) 553 (52%) 278 (26%) 502 161 123 975
(47%) (15%) (12%) (91%)
49 20 20 578
(5%) (2%) (2%) (54%)
446 (42%) 40 (4%)
Table 2 Percentage agreeing with negative statements in 1998, 2003 and 2008.
Danger to others Unpredictable Hard to talk to Selves to blame Not improved if treated Feel different from us Could pull self together Never fully recover
Schizophrenia
Depression
Anxiety
98
3
8
98
3
8
98
3
8
71 77 58 8 15 57 8 51
66 73 52 6 12 37 8 42
63 70 50 9 15 54 10 44
23 56 62 13 16 43 19 23
19 53 56 11 15 30 17 25
21 50 53 14 18 40 17 26
26 50 33 11 14 39 22 22
23 50 26 10 15 25 20 21
20 43 24 10 18 38 18 24
Table 3 Eigen values, individual and total variance explained for rotated factor solutions for schizophrenia, depression and anxiety.
Factor 1: Negative stereotypes Factor 2: Patient blame Factor 3: Inability to recovery Total variance explained
Schizophrenia
Depression
Anxiety
EV ¼2.44 V ¼ 30.41% EV ¼2.03 V ¼ 25.44% EV ¼1.035 V ¼ 12.94% 68.79%
EV ¼1.47 V¼ 18.09% EV ¼1.89 V¼ 23.56% EV ¼ 1.23 V¼ 15.33% 56.98%
EV ¼ 2.04 V ¼ 25.55% EV ¼ 1.40 V ¼ 17.50% EV ¼ 1.30 V ¼ 16.23% 59.28%
EV¼ Eigen value, V ¼ Variance explained.
51.048, p o0.001). Bonferroni post hoc analyses were conducted to indentify the significant differences between groups for each individual factor. For negative stereotypes, schizophrenia was significantly higher than depression (0.001) and anxiety (0.001), depression was significantly higher than anxiety (0.001), for patient blame schizophrenia was significantly lower than depression (0.001) and anxiety (0.001) and no difference was found between depression and anxiety (1.000), and for inability to recovery schizophrenia scored significantly higher than depression (0.001) and anxiety (0.001) and no difference was found between depression and anxiety (1.000).
4. Discussion This study aimed to examine the differences in public perceptions of different psychiatric diagnoses and compare public stigma attitudes towards schizophrenia, depression and anxiety. Data was taken from the ONS (2008) opinions survey which examined people's attitudes towards psychiatric diagnoses. Results were compared to Crisp et al. (2000, 2005) previous analyses and the general trend was that negative stigma views had improved slightly since 1998 across all diagnoses. The changing minds campaign, which observed between 1997 and 2003, had a positive impact on negative attitudes towards psychiatric diagnoses given the overall reduction in negative views in 2003. However, it appears that since this campaign ceased views have increased to comparable levels, albeit lower, of that identified in 1998. Public stigma campaigns which promote a positive perception of psychiatric diagnoses should therefore be continued on a long-term basis. For example, Time to change, a continuing UK public stigma campaign which aims to ‘inspire people to work together to end the discrimination surrounding mental health’ should be continued and long-standing. Its priorities are to reduce stigma through social contact and public education. Recent, evaluation of the efficacy of the campaign illustrated that
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Table 4 Rotated solution factor loadings for schizophrenia, depression and anxiety. Item
a. Danger to others b. Unpredictable c. Hard to talk to d. Selves to blame e. Not improved if treated f. Feel different from us g. Could pull self together h. Never fully recover
Factor 1: Negative stereotypes
Factor 2: Patient blame
Factor 3: Inability to recover
S
D
A
S
D
A
S
D
A
0.864 0.874 0.790 … … … … …
0.549 0.807 0.729 … … … … …
0.662 0.726 0.752 … … … … …
… … … 0.801 … 0.738 0.812 …
… … … 0.792 … 0.509 0.735 ….
… … … 0.718 … 0.616 0.783 …
… … … … 0.820 … … 0.648
… … … … 0.736 … … 0.728
… … … … 0.822 … … 0.750
S¼ Schizophrenia, D¼ Depression, A ¼Anxiety.
Table 5 Means and standard deviations of individual items and subscales for schizophrenia, depression and anxiety.
Factor 1: Negative stereotypes a. Danger to others b. Unpredictable c. Hard to talk to Factor 2: Patient blame d. Selves to blame f. Feel different to us (reversed) g. Could pull self together Factor 3: Inability to recover e. Not improve if treated h. Never fully recover
Schizophrenia
Depression
Anxiety
11.78 3.93 4.19 3.66 6.55 2.09 2.22 2.24 5.97 2.47 3.50
9.58 2.53 3.52 3.52 7.56 2.31 2.67 2.58 5.30 2.38 2.92
8.61 2.43 3.28 2.90 7.56 2.14 2.73 2.69 5.35 2.48 2.87
(2.75) (1.13) (1.08) (1.03) (2.70) (1.14) (1.15) (1.09) (1.67) (1.16) (1.05)
(2.49) (1.25) (1.13) (1.14) (2.40) (1.20) (1.14) (1.11) (1.89) (1.26) (1.13)
(2.57) (1.26) (1.20) (1.10) (2.47) (1.09) (1.17) (1.05) (1.87) (1.17) (1.11)
people who have mental health difficulties have experienced less stigma and discrimination since the campaign began (Time to Change, 2010). Three identical stigma factors emerged for each diagnosis which reflected themes identified in previous literature (Brocklington et al., 1993). This factor structure suggests that the same attitudes are important across all diagnoses and key to understanding public perceptions. Schizophrenia was viewed significantly more negatively than depression or anxiety in line with previous evidence (Angermeyer and Matschinger, 2003; Crisp et al., 2000, 2005). People diagnosed with schizophrenia are seen as more dangerous and less likely to recover than other diagnoses. Anxiety was seen most favourably by the public; it was associated with less negative stereotypes and seen as more likely to recover. Interestingly, anxiety and depression were seen almost identically for patient blame and incurred more blame than schizophrenia. Depression was associated with more negative stereotypes than anxiety which supports previous literature outlining that people who experience depression are viewed as lazy and not easy to talk to (Thornicroft et al., 2007). A previous review of the stigma literature has illustrated that negative public attitudes towards psychiatric diagnoses stem from perceptions that there is a biogenetic cause of the mental health problem (Lincoln et al., 2008). This may explain why negative perceptions of schizophrenia, depression and anxiety have reduced and patient blame and the inability to recover continue to increase. A way of tackling negative public attitudes is to promote psychosocial alternatives which move away from a biological cause which may seem more permanent. In a recent consensus study by Clement et al. (2010), recovery-orientated views (i.e. that recovery in psychosis is possible and achievable) and seeing the person (i.e. seeing the person not the diagnosis) were the most important messages to include in a public stigma
campaign. These messages are extremely likely to reduce all three negative perspectives identified in this study. This research also highlights the need to support people with mental health diagnoses, particularly schizophrenia, in coming to terms with the negative public attitudes towards psychiatric diagnoses. As outlined, stigma can be internalised and have a number of detrimental impacts on the individual, for example reduce self-esteem, cause depression and anxiety and impede recovery (Link et al., 2001). Arguably, because internalised stigma refers to an individual's negative beliefs about themselves, a Cognitive Behavioural Therapy (CBT) approach may be best placed to approach these issues and is recommended by National Institute of Clinical Excellence guidelines (NICE, 2009). Public attitudes of stigma and their impacts, if relevant to an individual's difficulties, should be made clear within an individual CBT formulation which will facilitate the use of important change mechanisms and facilitate recovery, for example, understanding the impacts of diagnosis, normalisation, positive data logs, evaluating the accuracy of internalised stereotypes, and understand the impacts of stigma upon core beliefs.
4.1. Strengths and limitations A strength of this study was the use of a large scale public database which facilitated examination of public attitudes in a representative sample. The attitudes shared within this sample are likely to be more reflective of the general population due to the large sample size. This study also suffered from typical limitations of large scale databases. The response rate was 60%, slightly lower than the previous two studies (Crisp et al., 2000, 2005), but close to the expected response rate for population survey studies. A lower response rate can risk sampling bias and threaten the accuracy of results. Moreover, the database comprised secondary data with pre-defined variables, restricting the scope of exploration for stigma. Questions were limited to eight five-point likert scale responses per diagnostic category. Further studies would benefit from examining attitudes in more detail and examining the public's perceived causes of the diagnoses to understand the relationship in more detail (Read and Harre, 2001).
4.2. Conclusion Negative public attitudes towards psychiatric diagnoses are still prevalent with schizophrenia being viewed most negatively by the public. Public campaigns such as changing minds was shown to have positive impacts on public attitudes toward mental health, however these changes were not long-lasting. Stigma campaigns need to be long-standing in order for sustained change to occur.
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