Background
The Attitudes to Mental Illness survey
The Attitudes to Mental Illness survey tracks changes in mental health knowledge and behaviour since 2009 and attitudes related to mental health since 2008. The research has been carried out annually in England since 2008, moving to every 2 years since 2017. Around 1700 respondents take part in each wave, selected by a quota sampling frame to produce a nationally representative sample of adults aged 16 and older. Respondents are not resampled in later surveys. The survey was carried out face-to-face until 2019. Due to changes caused by COVID-19, the 2021 and 2023 waves used a web or paper self-completion data collection approach.
There were 1638 respondents to the 2023 wave of the Attitudes to Mental Illness survey, with fieldwork carried out between March and May 2023 by Kantar, using the Address-Based Online Sampling method. The team at the Institute of Psychiatry, Psychology, and Neuroscience (IoPPN) at King’s College London Analysis has carried out analysis for every wave of the Attitudes to Mental Illness survey.
The theoretical approach underlying the Attitudes to Mental Illness survey comes from the work of Professor Sir Graham Thornicroft, Professor Claire Henderson, and colleagues at the IoPPN.[4]
It defines public stigma as having 3 components:
- Misunderstanding or ignorance of the nature of mental illness
- Strong negative feelings towards people with mental health problems
- Social actions such as discrimination or avoidance that marginalise or exclude people with mental health problems.
In other words, stigma is a social issue made up of problems of knowledge, attitude, and behaviour, and each of these domains of stigma can be quantified and tracked at the national level.
To measure attitudes, knowledge, and behaviour the survey uses multi-item, validated psychological scales to ensure reliability and validity. The research uses the 27-item Community Attitudes to Mental Illness (CAMI) scale to measure attitudes.
The CAMI scale has 2 component factors, measuring attitudes relating to prejudice and exclusion on the one hand and attitudes towards inclusion, tolerance, and community care on the other. Examples of items from the prejudice and exclusion factor include:
- ‘Locating mental health facilities in a residential area downgrades the neighbourhood’
- ‘Anyone with a history of mental health problems should be excluded from taking public office’
- ‘People with mental illness don’t deserve our sympathy’
Items from the tolerance and support for community care factor include:
- ‘People with mental illness have for too long been the subject of ridicule’
- ‘As far as possible, mental health services should be provided through community based facilities’
- ‘No-one has the right to exclude people with mental illness from their neighbourhood’
In other words, some of the statements in the full CAMI scale express stigmatising attitudes while others express destigmatising attitudes, and the scale measures both how exclusionary attitudes are and how much support for care in the community exists.[5]
The survey uses the 12-item Mental Health Knowledge Schedule (MAKS) to measure mental health-related knowledge, for example by asking respondents whether they think most people with mental health problems want to have paid employment. If the respondent correctly answers that most people with mental health problems do in fact want to have paid employment then they will score more highly on this item, with similar correct responses leading to an overall higher score on the MAKS scale.
Finally, the 8-item Reported and Intended Behaviour Scale (RIBS) is used to measure intended and reported behaviour towards people with mental health problems. Intended and reported behaviour is measured by asking respondents how willing they would be to live with, work with, live nearby, or have as a close friend someone with mental health problems and whether they have carried out the specified behaviour. The more willing, or the greater level of reported behaviour, the higher the score on the RIBS scale.
For the first time in 2023 we also measured the level of stigma around schizophrenia compared to that around depression. By repeating items used in the 2007 and 2015 British Social Attitudes Survey (BSAS), carried out by the National Centre for Social Research, we were able to compare how much respondents wanted to avoid someone with symptoms associated with depression compared to someone with symptoms associated with schizophrenia. In neither case was the diagnostic label (i.e. “schizophrenia” or “depression”) used. Questions related to assessing expectations of and attitudes towards workplace discrimination against people with these disorders as compared to a physical health comparator were also used, with data from BSAS respondents living in England only used to allow comparability.
Time to Change (2007-2021) and previous changes in stigma measures
From 2008 to 2021, the AMI research was commissioned by the Time to Change campaign. The 2023 wave was commissioned by Mind. Time to Change was a national intervention aimed at reducing mental health-related stigma and discrimination in England, delivered by the charities Mind and Rethink Mental Illness and funded by the Department of Health and Social Care, Big Lottery Fund, and Comic Relief.
Running from 2007 to 2021, Time to Change combined a behaviour change campaign with television advertising, organisational pledges, celebrity endorsements, and local community hubs. The campaign was grounded in the principle of 'social contact', or creating opportunities for people with lived experience of mental health problems to share their experiences with those who might not have lived experience.[6] Encouraging people to maintain contact (as opposed to avoidance), Time to Change delivered parasocial (virtual) contact or social contact and promoted empathy as a way to tackle prejudice.
Improvements were seen during the Time to Change campaign
Figure 1 shows the changes in the 3 measures of public stigma – knowledge, attitudes, and behaviour – observed between 2008/9 and 2019. The Attitudes to Mental Illness survey found positive, consistent change in all 3 stigma measures (CAMI, MAKS, and RIBS).[7] For behaviour (RIBS) an improvement was seen in 2012, for attitudes (CAMI) in 2013, and for knowledge (MAKS) in 2014. While this improvement supports the effectiveness of the Time to Change campaign, it cannot be definitively attributed to the campaign.
Figure 1: What happened after a decade of Time to Change?
As Figure 1 shows, the period 2008 to 2019 saw consistent improvement in the headline measures of stigma in a nationally representative sample of adults in England. By 2019 Time to Change was able to confidently say that over 5 million adults had improved attitudes towards people with mental health problems when compared with 2008.
Source: AMI 2023, analysis by Institute of Psychiatry, Psychology, and Neuroscience, KCL.
Notes
[4] See for instance Thornicroft et al (2007), ‘Stigma: ignorance, prejudice or discrimination?’
[5] In both cases respondents are asked for their level of agreement with the statements (using a 5-point Likert scale), with less stigmatising attitudes being coded as higher scores within the CAMI scale.
[6] See Lancet Commission on Ending Stigma and Discrimination in Mental Health (2022) for more on the evidence base around social contact.
[7] See Henderson et al (2020), ‘Mental illness stigma after a decade of Time to Change England’