Methods to reduce the stigma of mental illness

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, Goddard and Meltzer6} Crisp et al's large survey showed that people with substance use disorders were the most stigmatised of all those with mental disorder. ^{Reference Crisp, Gelder, Goddard and Meltzer6} More recently, national anti-stigma campaigns have been launched in Scotland (‘See me’) and England (‘Time to Change’), although unfortunately there have been reports that national anti-stigma campaigns are not particularly effective. ^{Reference Luty, Umoh, Sessay and Sarkhel14,Reference Paykel, Hart and Priest35,Reference Mehta, Kassam, Leese, Butler and Thornicroft36} These reports discuss the disappointing results to date from the ‘Defeat Depression’, the ‘Changing Minds’ and the Scottish ‘See me’ campaign. Although a significant amount of work has been undertaken on the stigmatising effect of a diagnosis of schizophrenia, very little research has looked at the stigmatised attitudes directed against people with intellectual disability. ^{Reference Corrigan, Markowitz, Watson, Rowan and Kubiak4,Reference O'Hara10,Reference Luty, Umoh, Sessay and Sarkhel14,Reference Penn, Kommana, Mansfield and Link37} For example, the stigma of intellectual disability is not addressed by either the ‘Changing Minds’ or ‘Time to Change’ campaigns or the UK government publication Action on Mental Health. ¹ Methods of dealing with stigma are not addressed in the UK Department of Health report, Valuing People, which specifically concerns people with intellectual disability. ¹⁷

Action on Mental Health ¹ provides 12 individual fact sheets to reduce stigma. This supplements the efforts of the ‘Changing Minds’ campaign. Both give practical advice to health agencies, employers and stakeholders to tackle stigma. Providing factual information in brief fact sheets ^{Reference Penn, Guynan, Daily, Spaulding, Garbin and Sullivan38,Reference Thornton and Wahl39} or through extensive interventions such as educational courses has been reported to reduce stigma. ^{Reference Corrigan and Penn34,Reference Mayville and Penn40-Reference Knox, Smith and Hereby42} Unfortunately, responses tend to be small, especially if negative consequences of mental illness are also disseminated. Knox et al showed that addressing stigmatised attitudes to mental illness among four million members of the US armed forces with mandatory training to recognise and treat mental illness significantly reduced suicide rates but not stigmatised attitudes. ^{Reference Knox, Smith and Hereby42} Pinfold et al reported a project in which 472 English secondary school children attended mental health awareness workshops. ^{Reference Pinfold, Toulmin, Thornicroft, Farmer, Huxley and Graham43} Overall, there was a small but positive shift in their understanding of mental illness. However, it was possible to argue that in both these settings participants engaged in anti-stigma training, whereas any involvement by the general public is entirely voluntary.

Penn et al reported a study of 163 US undergraduates who were assigned randomly to four groups: three watched a documentary about schizophrenia (represented realistically), polar bears or being overweight, and the fourth group was a ‘no video’ control group. ^{Reference Penn, Chamberlin and Mueser44} The schizophrenia documentary did not change attitudes. Depicting the negative consequences of schizophrenia may be realistic but may not be the best way to reduce stigma. Depicting a success story may be more effective, although viewers may then classify this as an exception to the rule. ^{Reference Corrigan and Penn34} By contrast another study showed that presenting individuals who had recovered from alcoholism in a positive manner can significantly reduce the stigma of alcoholism, however the effects for schizophrenia were negligible. ^{Reference Luty, Rao, Arokiadass, Easow and Sarkhel33} Luty et al also found that a brief face-to-face intervention (motivational interviewing) helped to reduce the stigma of alcoholism, although the effect was modest. ^{Reference Luty, Umoh and Nuamah45}

Promoting direct interpersonal contact with people who are mentally ill may be an effective strategy, but the amount of contact required has not been established. ^{Reference Corrigan and Penn34,Reference Penn, Guynan, Daily, Spaulding, Garbin and Sullivan38,Reference Pinfold, Toulmin, Thornicroft, Farmer, Huxley and Graham43,Reference Wolff, Pathare, Craig and Leff46} It would be difficult, in practice, to ensure that a significant proportion of the public had contact with people with a severe mental illness. Our report indicates that looking at pictures of people with intellectual disability and dysmorphic facial features reduces stigmatised attitudes significantly and this may act as an effective substitute for direct contact.

Strengths and limitations

The AMIQ was used in this project as it is convenient and has been well validated. ^{Reference Luty, Fakuda, Umoh and Gallagher28,Reference Cunningham, Sobell and Chow29,Reference Luty, Rao, Arokiadass, Easow and Sarkhel33} Other instruments are available, although these tend to be much longer, involve interviews or tend to address the experience of stigma by people with mental illness (e.g. the Internalised Stigma of Mental Illness scale ^{Reference Ritsher, Otilingam and Grajales47).Reference Luty, Fakuda, Umoh and Gallagher28}

Although there was an excess of female respondents, the age and employment status of participants were reasonably matched to that from UK census surveys. Hence the sample appears to be a reasonable cross-section of the British public. However, it is self-selecting and may not generalise across the whole population. Ideally, interviews could be conducted using a quota survey of households with repeat visits for non-responders. ^{Reference Crisp, Gelder, Goddard and Meltzer6} Unfortunately this is prohibitively expensive.

The study presented a hypothetical person with intellectual disability, as, it was not possible to measure stigmatised behaviour towards real people with intellectual disability. Moreover, the written views and expressed attitudes may not translate into any enduring behavioural change. Although there was no direct contact between participants and researchers, participants are likely to make some assumptions about the potentially liberal beliefs of researchers. Hence social desirability bias may affect the results. However, the results from other similar studies demonstrated a negative view of people with active substance use disorder and suggest that participants had little reservation about indicating their disapproval of these disorders. ^{Reference Luty, Fakuda, Umoh and Gallagher28,Reference Luty, Rao, Arokiadass, Easow and Sarkhel33} This is confirmed in other reports. ^{Reference Crisp, Gelder, Goddard and Meltzer6} This would indicate that social disability bias had only a modest effect. Furthermore, social desirability bias would affect both groups equally.

Funding

The research was supported by Southend MIND.