Stigma is a social construction that devalues people because of a distinguishing characteristic or mark. ^{Reference Biernat, Dovidio, Heatherton, Kleck and Hebl1} The World Health Organization and the World Psychiatric Association recognise that the stigma attached to mental disorders is strongly associated with suffering, disability and poverty. ^{Reference Corrigan, Markowitz, Watson, Rowan and Kubiak2} Stigma is also a major barrier to seeking treatment. ^{Reference Appleby3} Many studies show that negative attitudes towards the mentally ill are widespread, while the media generally depict mentally ill people as violent, erratic and dangerous. ^{Reference Granello, Pauley and Carmichael4,Reference Crisp, Gelder, Rix, Meltzer and Rowlands5}

Providing factual information in brief fact sheets ^{Reference Penn, Guynan, Daily, Spaulding, Garbin and Sullivan6-Reference Penn, Kommana, Mansfield and Link8} or through extensive interventions such as educational courses is reported to reduce stigma. ^{Reference Thornton and Wahl9-Reference Mayville and Penn11} These methods have been the basis of several anti-stigma campaigns. For example, the Royal College of Psychiatrists' Changing Minds campaign aimed to promote positive images of mental illness, challenge misrepresentations and discrimination, and educate the public to the real nature and treatability of mental disorder. ^{Reference Crisp, Gelder, Rix, Meltzer and Rowlands5} This campaign contributed towards Action on Mental Health: A Guide to Promoting Social Inclusion, a document of 12 fact sheets on reducing the stigma of mental illness, with practical advice to health agencies, employers and stakeholders. ^{Reference Penn and Martin12} More recently, national anti-stigma campaigns have been launched in Scotland (www.seemescotland.org.uk) and England (www.time-to-change.org.uk). Unfortunately, there have been reports that national anti-stigma campaigns are not particularly effective. ^{Reference Corrigan and Penn13-Reference Paykel, Hart and Priest15} These reports discuss the disappointing results from the English Defeat Depression and Changing Minds campaigns and the (Scottish) See Me campaign.

We wanted to assess whether promotional materials from the Time to Change campaign (postcards, leaflets and bookmarks) were likely to have any effect on public attitudes towards mental illness.

Method

Results

Completed questionnaires were received from 196 individuals (response rate 78%); 32% were male; mean age was 50 years (s.e. = 1.1); 56% were in paid employment; 92% described themselves as White British; 41% endorsed the item ‘Do you know anyone personally who has a serious mental illness (like schizophrenia) or someone who has been in a mental hospital?’

The mean score was +1.92 (s.e. = 0.29; s.d. = 2.91) for the 5-point AMIQ stigma scale. We compared this with a score from the AMIQ validation 3 years earlier on 1098 members of the UK general public: + 2.35 (s.e. = 0.10). ^{Reference Luty, Umoh, Sessay and Sarkhel16} There was no statistically significant difference in scores (Mann-Whitney U-test two-sided P = 0.0367; power (for 5% significance) = 55%).

Discussion

A single exposure to three forms of promotional materials from the Time to Change anti-stigma campaign (postcards, leaflets and bookmarks) had little discernable effect on public attitudes towards mental illness. There was no significant change on scores of the AMIQ when performed in respect to a fictitious man with depression who self-harmed. Only a minority of participants (less than 25%) recognised the logo, the name of the campaign, the ‘1 in 4’ message and the campaign objective. This was despite the fact that three brief items of campaign materials had been posted directly to participants only 14 days before the questionnaire. There also seemed to be significant confusion between the anti-stigma Time to Change campaign and campaigns by British political parties. For example, the Conservative Party is currently using several variations on the ‘time to change’ themes in its marketing - ‘vote to change’, ‘election to change’; online Fig. DS1). This was topical at the time of the survey (April 2009) in the run up to the European Parliament elections in June that year. A similar message is being promoted by most British political parties, including the Liberal Democrats. Almost as many participants believed that the Time to Change campaign was being used to promote the ‘Liberal Party’ and that its objective was to reduce discrimination towards mental illness (20% v. 24%). As the political campaigns are likely to intensify rather than diminish in the run up to the next UK general election (which must take place on or before June 2010), this is likely to increase the confusion and reduce the effectiveness of the Time to Change anti-stigma campaign.

A second problem of the Time to Change campaign is common to all promotional campaigns, including those of political parties and commercial product advertising. The general public is saturated with promotional literature and it is extremely difficult to get noticed and transmit any message. ^{Reference Luty, Fekadu, Umoh and Gallagher18,Reference Cunningham, Sobell and Chow19} Even factual stories in newspapers have little impact (e.g. on voting behaviour). Consequently, marketing campaigns and newspapers tend to associate their products or stories with publicly recognised celebrities. ^{Reference Luty, Fekadu, Umoh and Gallagher18,Reference Wilmshurst and Mackay20} Although the Time to Change campaign is endorsed and promoted publicly by celebrities such as Stephen Fry and Ruby Wax, they were not present on the materials used in our study.

It is unlikely that a single exposure to Time to Change materials would be effective. Although attempting to ensure repeated regular exposure over many months is prohibitively expensive, this is likely to be the only means of effecting significant ‘market penetration’ and attitude change.

There are now many suggested means of reducing the stigma of mental illness, including Action on Mental Health ^{Reference Penn and Martin12} and Changing Minds. ¹⁴ However, responses to these campaigns tend to be small, especially if negative consequences of mental illness are also disseminated. ^{Reference Jones, Kavanagh, Moran and Norton21} Pinfold et al ^{Reference Atkinson, Atkinson, Smith, Bem and Nolen-Hoeksema22} reported a project in which 472 English secondary school children attended mental health awareness workshops. Knox et al ^{Reference Penn, Chamberlin and Mueser23} studied addressing stigmatised attitudes to mental illness among 4 million members of the US armed forces, which involved mandatory training on recognition of mental illness. Although this significantly reduced suicide rates, there was no effect on stigmatised attitudes. It was possible in a military or secondary school setting to insist on engagement in anti-stigma training. By contrast, involvement of the general public in any campaign is entirely voluntary.

Promoting direct interpersonal contact with people who are mentally ill may be an effective strategy, but the amount of contact required remains unknown. ^{Reference Penn, Guynan, Daily, Spaulding, Garbin and Sullivan6,Reference Mayville and Penn11,Reference Penn, Chamberlin and Mueser23,Reference Pinfold, Toulmin, Thornicroft, Huxley, Farmer and Graham24} There was no significant effect of personal familiarity with a mentally ill person and stigmatised attitudes in our study, despite the fact that almost half of the respondents reported some familiarity with mental illness. This was also noted in an earlier study which showed no difference in the attitude of participants to people with alcoholism and those with opiate dependence, despite the fact that alcohol problems are several times more common in Britain than opiate dependence. ^{Reference Knox, Smith and Hereby25} This argues against the anti-stigmatising effect of direct contact with people with certain mental illnesses. Furthermore, it would be difficult in practice to ensure that a significant proportion of the public had contact with people with a severe mental illness.