Results
Attitudes, behaviour, and knowledge
The 2023 wave of the Attitudes to Mental Illness survey provides the most up-to-date picture of mental health stigma in England available. Although comparisons between the 2021/2023 waves and the 2019 and earlier waves are complicated by the effects of data collection moving from face-to-face to self-completion, the changes are stark when placed in the context of the period since 2008/9.
There’s a worrying trend in public stigma
Figure 2 shows the overall picture at the national level of knowledge, attitudes, and behaviour – the 3 component parts of public stigma.
Mental health-related knowledge and intended behaviour have strikingly fallen since 2019, while mental health attitudes have started to decline from 2021. Although the difference between 2021 and 2023 levels of attitudes is not statistically significant, the trend across all 3 measures is worrying.
Figure 2: What happened after Time to Change ended?
Source: AMI 2023, analysis by Institute of Psychiatry, Psychology, and Neuroscience, KCL.
To put the results in comparative perspective, in 2019 there were statistically significant improvements in all 3 measures – that is, knowledge, attitudes, and behaviour – when compared with the starting points a decade earlier. Following falls in knowledge and behaviour since 2019 and in attitudes since 2021, knowledge and behaviour have returned to 2009 levels while attitudes are now equivalent with those from 2014.
We at Mind feel that this is reason to be concerned about the possibility of backsliding and possible future worsening of mental health stigma.
What's driving the marked decline in headline stigma measures?
The Attitudes to Mental Illness survey is designed primarily to identify change rather than to explain it. Nevertheless, the component items of the 3 scales provide useful insights into what is driving change at the national level in the 3 stigma measures.
There’s been a change in attitudes towards community care
Within the CAMI scale of attitudes, as shown by Figure 3, overall changes are being driven by a decrease in the tolerance and support for community care. Previous improvements in the prejudice and exclusion scale have in very large part remained. Given that the prejudice and exclusion scale is designed precisely to measure the level of prejudicial and exclusionary attitudes among adults in England, this is real reason for hope: the gains of over a decade of reducing prejudice around mental health have been maintained.
What has changed is that English adults are now less likely to feel that the best therapy for many people with mental illness is to be part of a community or that mental health services should be provided through the community. Comparing 2019 and 2023, the decrease in the CAMI tolerance and support for community care scale is statistically significant.
Figure 3: What might be driving the marked decline in stigma measures?
Comparison of the CAMI prejudice and exclusion and CAMI tolerance and support for community care subscales.
Source: AMI 2023, analysis by Institute of Psychiatry, Psychology, and Neuroscience, KCL.
Within the MAKS scale, which measures knowledge, 2 items show a marked change between 2019 and 2023: ‘If a friend had a mental health problem, I know what advice to give them to get professional help’ (66.1% of respondents strongly or slightly agreeing in 2019 compared with 59.8% in 2023) and ‘People with severe mental health problems can fully recover’ (66.7% of respondents strongly or slightly agreeing in 2019 compared with 59.1% in 2023). In both cases, there seems to be increasing pessimism that help and support can be effective – particularly for people with less understood mental health problems.
Within the intended behaviour scale (RIBS-IB), change is being driven by the proportion of respondents strongly or slightly agreeing with the statements: ‘I would be willing to live with someone with mental health problems’ (69.3% of respondents strongly or slightly agreeing in 2019 compared with 55.0% in 2023) and ‘I would be willing to live nearby to someone with mental health problems’ (81.3% of respondents strongly or slightly agreeing in 2019 compared with 75.2% in 2023).
Overall, in relation to knowledge and attitudes, we might suggest that we are starting to see the increase of 'therapeutic pessimism', such that adults in England are less likely than before to believe that a community-based system of mental healthcare enables people with mental health problems to get better, to know how to help a friend get the right advice, or to think that recovery from a less well understood mental health problem is possible.
Mental health vignettes and workplace attitudes
Stigma around depression and schizophrenia
The 2023 wave of the Attitudes to Mental Illness also allows for an analysis of how the stigma around depression and schizophrenia may have changed over time through the introduction of 2 vignettes. These short accounts of the symptoms of 2 hypothetical individuals with mental health problems describe the experiences of 'Stephen' and 'Andy' but do not use the diagnostic labels 'depression' for Stephen or 'schizophrenia' for Andy (see Box 1 and Box 2). Having read the vignettes, respondents are then asked for their willingness or unwillingness to:
- Move next door to Stephen/Andy
- Spend time socialising with Stephen/Andy
- Make friends with Stephen/Andy
- Have Stephen/Andy as a workmate or colleague
- Have Stephen/Andy marry into the family
- Have Stephen/Andy provide childcare for someone in their family
Box 1: Stephen vignette
Stephen has been feeling really down for about 6 months and his family have noticed that he hasn't been himself. He doesn't enjoy things the way he normally would. He wakes up early in the morning with a flat heavy feeling that stays with him all day long. He has to force himself to get through the day, and even the smallest things seem hard to do. He finds it hard to concentrate on anything and has no energy.
Source: AMI 2023
Box 2: Andy vignette
Andy was doing pretty well until 6 months ago. But then things started to change. He thought that people around him were criticising him and talking behind his back. Andy heard voices even though no one else was around. These voices told him what to do and what to think. Andy couldn't work anymore, stopped joining in with family activities and started to spend most of the day in his room.
Source: AMI 2023
The vignette approach was also used in the British Social Attitudes Survey (BSAS) in 2007 and 2015. Although there are differences in samples between the AMI and BSAS, we can compare responses from England over time to give an indicative picture of change.
Figure 4: Mental health vignettes: Stephen (“depression”), compared with British Social Attitudes Survey 2007 and 2015.
Source: AMI 2023, analysis by Institute of Psychiatry, Psychology, and Neuroscience, KCL.
Figure 5: Mental health vignettes: Andy (“schizophrenia”), compared with British Social Attitudes Survey 2007 and 2015.
Source: AMI 2023, analysis by Institute of Psychiatry, Psychology, and Neuroscience, KCL.
Comparing 2007, 2015, and 2023, the vignettes show an increasing willingness to interact socially with both someone with symptoms associated with depression and someone with symptoms associated with schizophrenia. This increase is particularly marked in the case of someone with schizophrenia symptoms. The largest increase across any item is in the proportion of respondents willing to have someone with schizophrenia symptoms provide childcare for someone in their family, although this started from a low base.
The vignettes show a consistent, if narrowing, difference in the desire for social distance towards someone with schizophrenia symptoms and someone with depression symptoms. In other words, less common mental health problems still elicit a higher level of avoidance and shunning from adults in England, although things look to be improving. The biggest differences are in moving next door, marrying into the family, and providing childcare.[8]
Mental health stigma in the workplace
Finally, the Attitudes to Mental Illness 2023 survey also examined workplace attitudes. We can compare the 2023 findings with the British Social Attitudes Survey from 2015 for questions on perceived (Figure 6) and actual (Figure 7) stigma around diabetes (as a physical health point of comparison), depression, and schizophrenia.
As Figure 6 shows, perceived stigma has lessened for all 3 conditions when comparing 2023 with 2015. However, perceived stigma around schizophrenia is greater than that around diabetes. In other words, respondents are more likely to think that schizophrenia will affect someone’s likelihood of promotion when compared with diabetes.
Figure 7 illustrates that along with perceived stigma lessening for all 3 conditions when comparing 2023 with 2015, there is also no difference when comparing diabetes, depression, and schizophrenia in actual stigma. In other words, respondents are not more likely to think that schizophrenia should make a difference in the workplace when compared with depression or diabetes.
Notes
[8] For moving next door, 89.8% of respondents were willing when asked about someone with depression symptoms, compared with 78.2% when asked about someone with schizophrenia symptoms, a difference of 11.6%. For marrying into the family, 80.0% of respondents were willing when asked about someone with depression symptoms, compared with 72.1% when asked about someone with schizophrenia symptoms, a difference of 7.9%. And, for providing childcare, 60.8% of respondents were willing when asked about someone with depression symptoms, compared with 41.5% when asked about someone with schizophrenia symptoms, a difference of 19.3%. For comparison, the differences in the BSAS 2007 were 19% for moving next door, 15.6% for marrying into the family, and 13.6% for providing childcare.
