How mental health literacy and experience of mental illness relate to stigmatizing attitudes and social distance towards people with depression or psychosis: A cross-sectional study

Abstract

Background Evidence suggests that mental health literacy among the public is low, and stigmatizing attitudes are widespread. So far the effects of anti-stigma campaigns are small, and studies demonstrate that negative attitudes have been quite stable through recent decades. Aims To investigate the relationships between mental health literacy, experience of mental illness and stigmatizing attitudes/social distance towards people with depression or psychosis. Methods A cross-sectional study in which staff members from public services in Sweden (n = 1027) completed questionnaires covering demographic data, self-reported experience of mental illness, identification of a vignette for depression or psychosis, beliefs about helpful interventions for the illness presented in the vignette, and attitudes and social distance towards people with the illness. Results About 50% of participants could identify depression and less than 40% psychosis. A higher degree of mental health literacy was related to less stigma and social distance but mainly towards people with depression. A similar relationship was shown for having personal or family experience of mental illness and attitudes/social distance. Negative attitudes and social distance were significantly higher in all aspects measured towards a person with psychosis than a person with depression. Conclusions A higher degree of mental health literacy relates to more positive attitudes and less desire for social distance towards people with depression. The differences between depression and psychosis should be taken into account in anti-stigma interventions.

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How mental health literacy and experience of
mental illness relate to stigmatizing attitudes and
social distance towards people with depression or
psychosis: A cross-sectional study
Bengt Svensson & Lars Hansson
To cite this article: Bengt Svensson & Lars Hansson (2015): How mental health literacy and
experience of mental illness relate to stigmatizing attitudes and social distance towards
people with depression or psychosis: A cross-sectional study, Nordic Journal of Psychiatry, DOI:
10.3109/08039488.2015.1109140
To link to this article: http://dx.doi.org/10.3109/08039488.2015.1109140
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NORDIC JOURNAL OF PSYCHIATRY, 2015
http://dx.doi.org/10.3109/08039488.2015.1109140
RESEARCH ARTICLE
How mental health literacy and experience of mental illness relate to stigmatizing
attitudes and social distance towards people with depression or psychosis: A
cross-sectional study
Bengt Svensson and Lars Hansson
Department of Health Sciences, Faculty of Medicine, Lund University, Sweden
ABSTRACT
Background Evidence suggests that mental health literacy among the public is low, and stigmatizing
attitudes are widespread. So far the effects of anti-stigma campaigns are small, and studies
demonstrate that negative attitudes have been quite stable through recent decades. Aims To
investigate the relationships between mental health literacy, experience of mental illness and
stigmatizing attitudes/social distance towards people with depression or psychosis. Methods A cross-
sectional study in which staff members from public services in Sweden (n¼1027) completed
questionnaires covering demographic data, self-reported experience of mental illness, identification of
a vignette for depression or psychosis, beliefs about helpful interventions for the illness presented in the
vignette, and attitudes and social distance towards people with the illness. Results About 50% of
participants could identify depression and less than 40% psychosis. A higher degree of mental health
literacy was related to less stigma and social distance but mainly towards people with depression. A
similar relationship was shown for having personal or family experience of mental illness and attitudes/
social distance. Negative attitudes and social distance were significantly higher in all aspects measured
towards a person with psychosis than a person with depression. Conclusions A higher degree of mental
health literacy relates to more positive attitudes and less desire for social distance towards people with
depression. The differences between depression and psychosis should be taken into account in anti-
stigma interventions.
ARTICLE HISTORY
Received 17 April 2015
Accepted 13 October 2015
Published online
4 December 2015
KEYWORDS
Depression Mental health
literacy; Psychosis; Social
distance; Stigmatization.
Background
Mental disorders are common in the population and inflict a
large amount of morbidity and impairment. Estimations of
mental disorders in Europe indicate that around 27% of the
adult population suffer from some kind of mental disorder
every year (1,2). Highest prevalence is reported for anxiety
disorders, mood disorders dominated by major depression,
somatoform disorders and substance abuse (1). This leads to a
disability burden corresponding to 25–30% of the total
disability-adjusted life years (DALYs) lost in Europe (1).
Studies also show that only a minority of all cases gets
adequate consultation with professional health care services,
and there is a long delay between the recognition of the
disorder and the help given (3–5). The under-treatment of
mental disorders can partly be explained by self-limiting factors
such as fear of stigmatization and discrimination together with
a public lack of mental health literacy (5). Stigma is generally
referred to as a social construct comprising four interrelated
components: 1) people distinguish and label human differ-
ences, 2) labelled people are caused damage by cultural beliefs
and negative stereotypes, 3) labelled people are placed in
distinct categories to separate ‘‘us’’ from ‘‘them’’, and 4) labelled
people experience status loss and discrimination (6,7).
Stigmatizing attitudes appear to be widespread in society
and hinder recognition and appropriate help-seeking. In order
to improve mental health literacy and reduce negative
attitudes among the public, different campaigns have been
launched in Western countries. So far the strategies in anti-
stigma programmes have followed three approaches: personal
contact, education, and protest (8). Contact with people with
mental disorders appears to be the most effective approach,
followed by education, while protest has not shown any
significant change in fighting stigma (9). However, the effects
of anti-stigma programmes are small and longitudinal popu-
lation studies demonstrate that negative attitudes are quite
stable. There is a trend indicating a more positive attitude
towards psychiatric treatment and an improvement in abilities
to identify mental illness. Attitudes towards people with
mental disorders seem, however, to be unchanged. In fact,
over the last two decades attitudes towards people with
mental disorders have not improved and regarding people
with schizophrenia they have become even worse (10–12).
Despite a lot of anti-stigma programmes and extensive
research it appears to be difficult to find effective ways to fight
stigma against mental illness in the population (9–12).
Hopefully further research might clarify the most crucial aims
for interventions on a public level. This study investigates some
CONTACT Bengt Svensson Bengt.svensson@med.lu.se Department of Health Sciences, Faculty of Medicine, Lund University, Sweden
ß2015 Taylor & Francis
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of the factors that in earlier studies have shown a relationship
with attitudes towards mental illness such as mental health
literacy and personal contact with individuals affected (8).
Aim
The aim of the study was to investigate
whether better knowledge about mental illness influences
attitudes towards the people affected,
whether attitudes differ between people with personal or
family experience of mental illness and people without
such experience,
whether attitudes towards people with depression or
psychosis differ,
whether there are differences between men and women.
Participants and methods
The design is a cross-sectional study. Data represents the base-
line measurements from one randomized controlled trial and
one quasi experimental trial with pre- and post-testing
performed to evaluate a project about implementation of
mental health first aid (MHFA) (13) in Sweden.
Participants in the study were staff members from the
Swedish social insurance agency, employment agencies, social
services, schools, police departments, correctional treatment
centres, rescue services and recreation centres who applied for
the MHFA course. The study took place in two different
counties, one in the south west of Sweden and one in the
north. The county in the south west is a densely populated
area with about 1.6 million inhabitants and includes the second
largest city in the country, Gothenburg, and two medium sized
cities, Falko
¨ping and Va
¨nersborg. The county in the north is a
rural area with a population of about 215 000 inhabitants,
including the city of Umea
˚, with around 80 000 inhabitants.
Assessment was administered by mailed questionnaires with
reply envelopes sent to participants. The questionnaires covered
sociodemographic characteristics of the participant, why he/she
was interested in doing the course, self-reported history of
mental health problems in the participant or their family,
confidence in providing help, contact with people who have
had mental health problems in the previous 6 months and help
offered, recognition of a disorder in vignettes describing a person
with depression or schizophrenia/psychosis and beliefs about the
helpfulness of various interventions for the person described.
The instrument for rating helpfulness was created by
Kitchener and Jorm and been used in earlier studies (14).
Participants rated a list of people, treatments and actions that
the person in the vignette might use. The question was
formulated as ‘‘If [the person in the vignette] was to seek help
from any of the following people, is it likely to be ‘helpful’,
‘harmful’, ‘neither’ or ‘don’t know’ for her/his problem?: a
typical GP; a pharmacist; a counsellor; a social worker;
telephone counselling; a psychiatrist; a clinical psychologist;
help from her/his family; help from some close friends; a
neuropath or herbalist; the clergy; a minister or priest; the
person tries to deal with her problems on her own.’’ This was
followed by a list of medications: vitamins and minerals, St
John’s wort, pain relievers, antidepressants, antibiotics, sleep-
ing pills, antipsychotics, tranquillizers. Finally the participants
scored a list of other strategies: becoming more physically
active such as playing more sport, or doing a lot more walking
or gardening, reading about people with similar problems and
how they have dealt with them, getting out and about more,
courses on relaxation, stress management, meditation or yoga,
cutting out alcohol altogether, counselling, cognitive behav-
iour therapy, psychotherapy, hypnosis, admission to the
psychiatric ward or hospital, electroconvulsive therapy (ECT),
having an occasional alcoholic drink to relax, a special diet or
avoiding certain foods. Correct answers about the helpfulness
of the different people, treatments and actions are based on
consensus from a survey of professionals (15). The maximum
score for the depression vignette is six including GPs, psych-
iatrists, clinical psychologists, antidepressants, counselling and
cognitive-behaviour therapy. For the schizophrenia vignette
the maximum score is five including GPs, psychiatrists, clinical
psychologists, antipsychotics and admission to a ward. A social
distance scale to assess stigmatizing attitudes is also included
(16). The questions in this scale ask how willing (1 ¼definitely,
2¼rather not, 3 ¼definitely not) respondents would be to 1)
move next door to the person described in the vignette, 2)
make friends with the person, 3) work closely with the person,
and 4) have the person marry into the family. To investigate
attitudes the personal and perceived Stigma Scale was used
(17). The scale was originally developed to investigate stigma
towards people with depression and comprises 18 items. Nine
of the items ask the participant to rate how strongly they
personally agree with statements about the person presented
in the vignette (depression or schizophrenia) and the other
nine questions ask about what they think other people believe
about the same issue. In this study only the personal part of
the scale is used. Ratings are made on a five-point Likert scale
and higher scores indicate less stigmatizing attitudes. The
items include whether the described disorder is a real medical
illness, to what extent it is under personal control, whether the
disorder is a sign of weakness, whether a person with the
disorder is dangerous or/and unpredictable, whether to feel
shame or/and conceal the illness if stricken by it, avoidance of a
person with the disorder and discrimination in terms of ‘‘not
voting for a politician with the disorder’’ and ‘‘not employing
someone with the disorder’’. Psychometric testing of the scale
has demonstrated acceptable properties concerning internal
consistency (17) and test–retest reliability (18). The internal
consistency of the scale for the present sample was 0.76
(Cronbach’s alpha).
A final question covered whether the participant or a family
member had ever had a problem such as the one described in
the vignette. The vignettes describing depression and schizo-
phrenia were given alternately to the participants.
Statistical analyses
Differences in demographic variables were investigated by chi
2
analysis for dichotomous variables and with independent
samples t-test for continuous variables. Differences between
groups were investigated with the independent samples t-test.
Alpha was set to 0.05. In all analyses SPSS statistics version 20
2B. SVENSSON AND L. HANSSON
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was used (IBM, New York, NY). Effect sizes (ES) were calculated
using Cohen’s d (19).
Results
The number of eligible participants was 1647; of these 620
declined to participate in the study which gave a final sample
of 1027 individuals. No differences concerning background
characteristics or familiarity with mental health problems were
found between those who completed the questionnaire with
the depression vignette (n¼506) and those who completed
the vignette for psychosis (n¼521). Characteristics of the
participants are presented in Table 1.
The participant ratings of possible interventions to help
someone with depression or psychosis and adequate staff
category to give help are presented in Table 2. For both
depression and psychosis psychologists and psychiatrists were
identified as important individuals to seek help from and for
depression antidepressants were believed to be helpful as well
as antipsychotics for psychosis. In general the respondents had
high confidence in the helpfulness of counselling, physical
activity, cognitive behavioural therapy and psychotherapy in
general.
Highly significant differences between reported social dis-
tance towards depression and psychosis were found. In all
aspects measured the social distance was higher towards
psychosis than towards depression (Table 3).
Among the participants who completed the questionnaire
with the depression vignette, 50.1% made a correct identifi-
cation of the condition and among those with the psychosis
vignette, 38.1%. Women were significantly better on identify-
ing the vignettes than men. The gender differences for
depression were chi
2
p50.01, and for psychosis chi
2
p50.05.
Men also showed more negative attitudes than women
according to the personal Stigma Scale (depression, p50.05,
ES 0.26, psychosis p50.001, ES 0.45) and were more negative
about having a person with depression married into the family
(p50.05, ES 0.29).
A correct identification of the vignette might be seen as an
indicator of a higher level of mental health literacy resulting in
less social distance. This appears to be true for depression
where those who made a correct identification reported more
positive attitudes (p50.001, ES 0.53) and a lower level of social
distance in all respects: become a neighbour (p50.001, ES
0.20), become a friend (p50.001, ES 0.33), become a colleague
(p50.001, ES 0.46) and finally to have someone married into
the family (p50.001, ES 0.29). For the psychosis vignette the
only finding was more positive attitudes according to the
personal stigma scale among those who made a correct
identification (p50.01, ES 0.22).
The percentage of participants who showed 100% agree-
ment with health professionals concerning adequate help-
giving and recommended treatment were 49.8% for depres-
sion and 37.2% for psychosis. The group with 100% agreement
concerning help-giving and treatment for depression also
reported less social distance according to personal stigma and
to have a person with depression married into the family. Only
one difference among those who answered the psychosis
vignette was found. Participants who had a 100% agreement
showed a more positive attitude to become a neighbour with a
person with psychosis (Table 4).
Among the participants, 23% reported personal experience
of mental illness and 44.6% personal experience of mental
illness in the family. Analyses to investigate whether these
Table 2. Percentage of respondents rating each intervention as helpful for
depression/psychosis.
Intervention
Depression
(n¼506)
Psychosis
(n¼521)
Person
General practitioner 77.0 64.2
Pharmacist 13.3 7.7
Counsellor 91.8 74.3
Social worker 27.1 32.7
Telephone counsellor 62.6 40.0
Psychiatrist 89.1 98.0
Psychologist 95.6 93.6
Close family 72.5 52.9
Close friends 80.4 57.9
Naturopath 18.0 5.5
Clergy 58.1 33.1
Deal with alone 9.0 2.1
Medication
Vitamins/minerals 21.7 7.3
Pain relievers 0.8 1.0
Antidepressants 88.4 69.3
Antibiotics 1.6 0.6
Sleeping pills 60.0 46.3
Antipsychotics 26.8 89.8
Tranquillizers 12.2 28.7
Other interventions
Physical activity 90.4 70.5
Read about problem 53.4 42.7
Get out more 25.9 17.5
Learn relaxation 87.3 50.7
Cut out alcohol 64.0 66.3
Counselling 93.1 75.0
Cognitive behavioural therapy 84.7 74.5
Psychotherapy 79.9 88.2
Hypnosis 16.7 12.3
Psychiatric ward 33.8 80.0
Electroconvulsive therapy 22.9 25.7
Occasional drink 1.2 1.0
Special diet 9.0 9.1
Table 3. Differences in stigma and social distance between the depression
vignette and the psychosis vignette.
Depression
(n¼506)
Mean (SD)
Psychosis
(n¼521)
Mean (SD) F value pvalue*ES
Personal stigma scale 36.2 (5.0) 33.7 (4.9) 0.3 50.001 0.50
Become a neighbour with X 1.2 (0.5) 1.7 (0.6) 44.2 50.001 0.91
Become a friend with X 1.3 (0.6) 1.7 (0.6) 8.0 50.001 0.67
Become a colleague with X 1.6 (0.7) 1.9 (0.6) 37.5 50.001 0.46
X married into family 1.7 (0.7) 2.2 (0.6) 48.0 50.001 0.77
*Independent sample t-test.
ES, effect size (Cohen’s d).
Table 1. Demographic characteristics of the participants in the study (n¼1027).
Variables % (n)
Age, mean (SD) 46.2 (11.0)
Women 78.6 (807)
University/college education 68.2 (700)
Born in Sweden 93.7 (962)
Personal experience of mental illness 23.0 (236)
Experience of mental illness in the family 44.6 (480)
Met someone with mental illness during the last six months 81.5 (837)
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experiences had any impact on stigmatizing attitudes were
made. For psychosis, personal experience of mental illness
resulted in a lower level of personal stigma. However, the
differences between those with and without experience were
small (p50.05, ES 0.22). Experience of mental illness in the
family showed a tendency to reduce personal stigma but did
not reach significance (p50.055, ES 0.17). There were no
differences in willingness to become a neighbour, friend,
colleague or having a person with psychosis married into the
family.
For depression, personal experience showed a lower level of
personal stigma (p50.05, ES 0.27), more willingness to become
a colleague (p50.05, ES 0.25) and to have a person with
depression married into the family (p50.001, ES 0.40). The
experience of mental illness (depression) in the family also
influenced towards more positive attitudes. The level of
personal stigma was lower (p50.001, ES 0.34) they showed
more willingness to become a neighbour (p50.05, ES 0.20) and
to have a person with depression married into the family
(p50.05, ES 0.22).
Discussion
This study is not representative of the population in Sweden.
Rather, it is representative of well-educated women working in
professions where they often meet clients in need of some kind
of psychological or psychiatric service. Furthermore, many of
the participants have received basic education in mental health
in their vocational training, e.g. social workers, employment
officers. Consequently it can be expected that their level of
mental health literacy in general is quite high. Among the
participants, 98% agree that a psychiatrist is the best helper for
a person with psychotic symptoms and 90% believe that anti-
psychotic medication is helpful for these symptoms. The vast
majority recommend a psychologist for people with depres-
sion and state that psychotherapy and anti-depressants are
effective treatments. The results indeed indicate a high level of
mental health literacy. Concerning stigmatizing attitudes and
social distance, a significant difference was found between
depression and psychosis. People are clearly more negative
and more inclined to dissociate themselves socially from a
person with psychosis than from a person with depression. This
finding corresponds with earlier research. The only condition
facing a stronger rejection than psychosis appears to be
alcohol dependence (11,20).
Women identified the conditions in the vignettes more
often than men. They also had more positive attitudes towards
both individuals with depression and psychosis. The reason
might be a gender difference but so far research has shown
inconsistent results in this matter. In an extensive review by
Angermeyer & Dietrich a majority of the studies examined did
not show any association between gender and attitudes (20).
Two Scandinavian studies have found that women compared
to men have more positive attitudes, but these studies did not
take the level of mental health literacy into account (21,22). If
greater success in identifying the vignettes is seen as a proxy of
mental health literacy this might be the factor that leads to
more positive attitudes (23). Unfortunately, the gender distri-
bution in the sample of this study does not make it relevant to
analyse the interaction between gender and mental health
literacy. Otherwise the results show that correct identification
of the vignettes and having 100% agreement with health
professionals about treatment are associated with more
positive attitudes and less desire for social distance. This
appears to be true for depression but only to a small extent for
psychosis, however. Regarding the aspects of having a person
with psychosis married into the family and to become a
neighbour with a person with psychosis, a higher level of
mental health literacy tends to be related to more desire for
social distance. This finding is not that surprising. Similar results
have been described both in population studies (24) and in
studies of targeted interventions aimed at reducing stigma by
improving knowledge about mental health issues. Improved
knowledge may not necessarily decrease the desire for social
distance (25–27).
Personal experience of mental illness or experience of
mental illness in the family shows a similar picture as the other
results from the study. Attitudes as well as the assessments of
social distance are more positive among participants who have
experienced mental health problems themselves or in the
family, but mainly towards people with depression. Concerning
psychosis, personal or family experience does not seem to have
much impact on either attitudes or social distance. Meta-
analyses have demonstrated that contact with individuals with
mental health problems within anti-stigma programmes (9)
seems to be the most efficient intervention to bring about a
positive change. However, having a family member affected by
mental illness or being personally affected probably produces
different experiences than formal and temporary contacts with
individuals in a programme. Perhaps it is more interesting to
compare results from studies of mental health staff and
mentally ill patients. In one study it was reported that staff
members treating patients with psychosis in particular had
negative attitudes and that the patients themselves to a great
extent shared the same attitudes (28).
Conclusions
A higher degree of mental health literacy is related to more
positive attitudes and less desire for social distance towards
Table 4. Differences between having a complete or incomplete agreement with
health professionals concerning help-giving and treatment.
Complete
agreement
(n¼252)
Mean (SD)
Incomplete
agreement
(n¼254)
Mean (SD) F value pvalue*ES
Depression
Personal Stigma Scale 36.9 (4.4) 35.3 (5.3) 6.8 50.001 0.33
Become a neighbour with X 1.2 (0.5) 1.3 (0.5) 3.2 ns 0.20
Become a friend with X 1.3 (0.6) 1.4 (0.6) 3.7 ns 0.17
Become a colleague with X 1.6 (0.7) 1.7 (0.6) 6.0 ns 0.15
X married into family 1.6 (0.7) 1.8 (0.7) 2.5 0.001 0.29
Psychosis (n¼194) (n¼327)
Personal stigma scale 33.8 (4.7) 33.6 (5.0) 3.0 ns 0.04
Become a neighbour with X 1.8 (0.6) 1.7 (0.6) 7.2 0.01 0.33
Become a friend with X 1.7 (0.6) 1.7 (0.6) 3.7 ns –
Become a colleague with X 2.0 (0.6) 1.9 (0.7) 7.2 ns 0.15
X married into family 2.2 (0.6) 2.1 (0.6) 0.0 ns 0.17
*Independent sample t-test.
ES, effect size (Cohen’s d), ns ¼not significant.
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individuals with depression. The difference between people
with psychosis and depression should be taken into account
when delivering anti-stigma interventions.
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