Main findings

The report shows that there was no statistical difference between stigmatised attitudes towards a person with a mental illness whether he was presented as ill or stressed. The medial difference of 1 unit is also unlikely to be of any practical significance as, in practice, the AMIQ scores range from –5 to +5 and a difference of less than 10% is unlikely to be meaningful. ^{Reference Luty, Fekadu, Umoh and Gallagher2} It is also clear that the vignette was able to convince participants that the illness did or did not arise from stress. (Presenting the individual as ‘stressed’ trebled the number of participants who endorsed this as the principle cause of his illness.)

One of the principle problems in interpreting these results is the vagueness of the concept of illness and stress. In his editorial, ^{Reference Kingdon1} David Kingdon attempts to grapple with this. The impression is given that mental illness is a reaction to stressful events in essentially normal (‘healthy’) people. By implication, the illness model would suggest that people who have a mental illness have a persistent defect of anatomy, physiology or biochemistry that is quantitatively different to normal (e.g., people with diabetes do not produce enough insulin). However, one problem with the stress model remains, and that is why do ‘normal’ mentally ill people react differently to stressful events that the majority of people can deal with? Perhaps they do have some underlying biological defect that only reveals itself under stress?

Although the project attempted to devise vignettes that were worded to coincide with the illness and stress models of mental disorder, there remains some controversy regarding this partly because there is no strictly accepted definition of these two models. Furthermore, both vignettes use the term ‘depressed’. It is likely that most participants regard the term ‘depression’ as synonymous with ‘miserable’ rather than a more restricted psychiatric diagnosis such as ‘major depressive illness’. The vignettes were devised by a group of health professionals and were also validated by interview with members of the general public. It was difficult to devise a suitable wording for any of the vignettes that present mental illness without using phrases that have psychological connotations. However, the effect of labelling is a subject that could be addressed in further research.

It is widely held that one reason for stigmatised attitudes towards people with mental illness is that they are ‘blameworthy’. ^{Reference Corrigan, Markowitz, Watson, Rowan and Kubiak5,Reference Crisp, Gelder, Goddard and Meltzer6} For example, patients are not blamed for biological or organic disorders such as diabetes, but they may be held responsible for psychological disorders such as mental illness. However, the research does not consider the ethical dimension to the aetiology of mental illness. In particular, it would be unethical to publicise the view that some patients had a biological cause to their mental illness, if the evidence was scanty or speculative. Of course, the aetiology of many psychiatric disorders remains uncertain. Ultimately, ethical questions are seldom amenable to experimental research as reported in the present study.

Tackling stigma and inequalities in health is a major UK government objective. ^{7,Reference Darzi8} Stigma is a social construction that devalues people due to a distinguishing characteristic or mark. ^{Reference Biernat, Dovidio, Heatherton, Kleck and Hebl9} 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 Kubiak5} Stigma is also a major barrier to treatment-seeking. ^{Reference Appleby10} Many studies show that negative attitudes towards individuals who have a mental illness are widespread. ^{Reference Crisp, Gelder, Goddard and Meltzer6} The media generally depicts such people as violent, erratic and dangerous. ^{Reference Granello, Pauley and Carmichael11} There have been several attempts to reduce the stigma of mental illness, including the Royal College of Psychiatrists’ Changing Minds campaign, the Scottish See Me campaign and Time to Change campaign in England. Unfortunately, there have been reports that national anti-stigma campaigns are not particularly effective. ^{Reference Paykel, Hart and Priest12-Reference Mehta, Kassam, Leese, Butler and Thornicroft14} These reports discuss the disappointing results to date from the Defeat Depression, Changing Minds and See Me campaigns.

Our report suggests that participants were prepared to accept that a mental illness such as depression may be caused by a chemical imbalance in the brain or stress in an otherwise healthy individual. However, these different presentations had no effect on stigmatised attitudes towards the fictitious patient. Consequently, this research suggests that anti-stigma campaigns are not likely to benefit by reframing mental illness as either biological or due to stress (indeed, the stress model actually elicited more stigmatised attitudes than the biological model). This contrasts with other research which suggests that stigma and social distance is greater when members of the public suspect that there may be a biological cause for mental illness. ^{Reference Penn, Guynan, Daily, Spaulding, Garbin and Sullivan15} In their survey of over 5000 German adults on the presentation of schizophrenia, Angermeyer et al ^{Reference Angermeyer, Beck and Matschinger16} reported that, ‘Endorsing biological factors as a cause was associated with increased social distance’. The desire for social distance was also predicted more strongly by other factors including perceived dangerousness, unpredictability, poor prognosis and, paradoxically, blame for causing their own illness. Angermeyer et al's report sought to determine which preconceptions predicted stigmatised attitudes, rather than attempting to challenge these. ^{Reference Biernat, Dovidio, Heatherton, Kleck and Hebl9,Reference Angermeyer, Beck and Matschinger16} Life events, psychosocial stress and biological factors (such as brain disease) were each considered major aetiological factors for schizophrenia by over half of the sample. The difficulty in interpreting this study is the problem in separating stigmatising factors that may be interrelated. For example, one interpretation of Angermeyer et al's results is that people with a stigmatised view of schizophrenia may, coincidentally, have the view that schizophrenia is both untreatable and has a biological cause. These participants may be more sympathetic to people with a biological illness than those with a psychological disorder but this is overwhelmed by the perceived dangerousness and untreatability of the condition. Hence Angermeyer et al's report cannot be used to conclusively suggest that members of the public have more stigmatised attitudes towards people with mental illness that has a biological cause. The authors’ concern about perceived biological causes of mental illness also contrasts with much other work on attributions theory which supports the view that stigmatised attitudes may be reduced in cases where the disorder has a biological cause. ^{Reference Biernat, Dovidio, Heatherton, Kleck and Hebl9,Reference Angermeyer, Beck and Matschinger16}

Strengths and limitations

The AMIQ tool was used in this project as it is convenient and has been well validated. ^{Reference Luty, Fekadu, Umoh and Gallagher2,Reference Luty, Kumar and Stagias4,Reference Luty, Rao, Arokiadass, Easow and Sarkhel17} 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.

Although there was an excess of female respondents and people not working, 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 report is actually a randomised controlled trial. Hence, if the research was repeated with other samples from the general public the AMIQ stigma scores may be different but the overall results are likely to be the same - that stigmatised attitudes are similar regardless of whether patients are presented as having a biological illness or experiencing stress.

The study presented a hypothetical person with mental illness. This is less accurate than real experience - it was not possible to measure stigmatised behaviour towards real patients. 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 show 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, Kumar and Stagias4,Reference Luty, Rao, Arokiadass, Easow and Sarkhel17} This is confirmed in other reports. ^{Reference Crisp, Gelder, Goddard and Meltzer6} This would indicate that social desirability bias had only a modest effect and it would affect both groups equally.