Attitudes towards community mental health care of residents in North London

the This descriptive, exploratory study attempts to to

This descriptive, exploratory study attempts to describe public attitudes towards the decision to close psychiatric hospitals and to identify their needs for preparation before patients move into their neighbourhood.

The study
A study and a control group of residents identified from the electoral roll were inter viewed on two occasions, before and after patients moved into a mental health facility in their neighbourhood. The study group consisted of 100 of the immediate neighbours of patients moved from a long-stay ward at a hospital to a community facility in North London. The control group comprised 100 of the residents of a road parallel to that of the study group, to minimise the likelihood of contact with the patients in the study area. Initially it was planned to interview the head of each household. However, due to difficulty in contacting this person each time, it was decided to concentrate on finding a family member who would participate. Contact with local residents was established by letter before the first interviews. At this stage no informa tion was given concerning either the hospital closure or the opening of the community mental health facility.
The participants were from a variety of cultures. The majority were unemployed and living in high-rise urban council flats. Doorto-door interviews were conducted using a semi-structured interview technique. Each participant was interviewed on two occasions: before patients moved into their neighbour hood and six months after the opening of the facility.
The response rate for the initial interview was 72%; 23% refused to participate on the doorstep and 5% sent the letter back with a notice of refusal. One-third of the interviewees were lost in the second interview.
The semi-structured interview schedule was designed to elicit the following information: demographic characteristics of the respon dents, perceptions of mental illness, opinion about hospital closure and reactions to the patients' transition into the community.

Findings
There were no significant differences in re sponses, given cultural and educational back ground, age or sex. The findings showed that similarity between both groups extended to their reactions towards the hospital closure decision. Therefore, the results presented represent the views of both groups.
Mental illness was perceived by (68%) as being of only two types: schizophrenia, a "serious illness", and depression or nervous breakdown which is "mild and curable" and did not evoke fear ofviolence among local residents. Even though residents could not distinguish between the mentally ill and mentally handi capped, they showed sympathy towards the term mental handicap. This was expressed by their willingness to donate money to charitable organisations for the mentally handicapped only. Mentally ill people were considered the least favourable neighbour. Local residents indicated that they would rent a room or a flat to people with diabetes, epilepsy and mental handicap but not mental illness. The mentally ill were associated with vagrancy and alcohol problems.
The majority (80%) of the respondents regarded social factors as a main cause of mental illness, such as divorce, death in the family, unemployment, high work load, poor housing conditions, stress and pressures of life. Even though local residents could not recognise those former psychiatric patients who had lived in their neighbourhood for six months, they associated mentally ill people with violence, physical assault, difficult com munication or bizarre behaviour.
Less than half (46.8%) were against the decision to close hospitals with equal numbers in favour or indifferent to change. Even though they strongly objected to the closure of psychia tric hospitals, they welcomed the opening of mental health facilities in the community-as long as they were not at the expense of hospital facilites. The public considered the decision as being ofadvantage to the politician rather than in the public interest. They stated that as physical illness is treated in general hospitals so mental illness should be treated in psychiatric hospitals.
Unexpectedly most respondents (88.6%) were in favour of opening mental health facilities in their area. This ambiguity may account for the difference in attitudes towards the settings of long-term care and of psychiatric treatment, and for the difficulty respondents had in recognising community sheltered settings as an alternative to admission to hospital.
Although the majority of the local residents (91%) chose treament in psychiatric hospitals for their relatives they preferred treatment in the community for themselves. The reasons for admission to hospital were regarded as the GP's recommendation, nobody to look after them at home, being a danger to others or themselves, needing company and the specia lisation of psychiatric hosptials.
Opinions were divided about whether former psychiatric patients could live in the commu nity with appropriate support. A quarter of the residents felt this was possible while a quarter felt it was not; the remaining respondents believed 24-hour staff support could be re quired. Most respondents expressed concern about the presence of former psychiatric patients in their area as they considered the area too "rough" and the road was very busy so that they might get knocked over by traffic. These views suggest that the public perceive mentally ill people as different and in need of hospital protection.
Sixty-seven per cent indicated that it is important to prepare residents before the opening of mental health facilities. Half the respondents were interested in knowledge about mental illness such as causes, preva lence and treatment, while 15% were inter ested in available services and practical skills required for dealing with former psychiatric patients in the community. They also re quested information about specific patients moving into the neighbourhood.
Eighty per cent said they would like to be told about mental health facilities opening in their area beforehand. The reasons included the wish to know how to treat patients to avoid clashes, while others wanted to keep their distance. Some respondents wanted "to know what is happening in the area"? or felt "[they] might need to move further away". This indicates the importance of providing the opportunity for the public to discuss and understand the behaviour of emotionally dis turbed people and calming their fears. Local residents who considered that education about mental illness was not needed claimed that publicity about mentally ill people could increase public prejudice or fear of mental illness. An analogy was drawn with the pub licity about AIDS.
Fifty-eight per cent of the respondents sug gested that education should be carried out by the NHS (hospitals, doctors and nurses), 14% suggested social services, 14% mental health facilities within the area, 8% the local council, and 6% a charitable organisation such as MIND. They suggested that the presence of patients could be useful as this would give them practical experience of mental illness. The preferred mode of education was through the media, and door-to-door discussion followed by newsletters. Local residents suggested a pro gramme of public education (incorporating practical skills, knowledge about mental ill ness, services available and the importance of accepting people with mental illness) should attempt to reach out to ethnic minority com munities by using their languages.

Comment
There is a limitation in generalising the results due to the homogeneity of the sample, being working class only, the short interval between both interviews and the small sample size.
Lack of significant changes in public percep tion over time are possibly due to a Type 2error due to small sample size or to response bias of the local residents. However, the lack of change in public attitudes could be a genuine finding, especially as the patients were pro tected from contacting members of the public by the staff. One resident commented "these patients (residents in the facility) are all elderly and accompanied by the staff all the time".
Contact with mentally ill people is not enough to change public perceptions of mental illness. Projects to educate the public should target smaller groups rather than large com munities. The design of these projects should be directed towards local residents who ex press willingness to help and support former psychiatric patients as well as those who are neutral in their views. Staff members of various community mental health facilities are in a good position to influence public opinions over a long term through their interaction with the public. Education about mental health should be introduced as part of mental health provision and as promoting mental health in the general population. The result suggested replication of public inter views, using a larger sample size from various sectors of the community (working and mid dle class areas) and a longer length of followup, for example, one year would be beneficial. Qualitative rather than quantitative ap proaches may provide valuable information in the planning of future development in mental health.