Author: Manderscheid, R; Delvecchio, P; Marshall, C; Palpant, R G; Bigham, J; Bornemann, T H; Kobau, R; Zack, M; Langmaid, G; Thompson, W; Lubar, D
Date published: May 28, 2010
Journal code: IMMW
Negative attitudes about mental illness often underlie stigma, which can cause affected persons to deny symptoms; delay treatment; be excluded from employment, housing, or relationships; and interfere with recovery (1). Understanding attitudes toward mental illness at the state level could help target initiatives to reduce stigma, but state-level data are scant. To study such attitudes, CDC analyzed data from the District of Columbia (DC), Puerto Rico, and the 35 states participating in the 2007 Behavioral Risk Factor Surveillance System (BRFSS) (the most recent data available), which included two questions on attitudes toward mental illness. Most adults (88.6%) agreed with a statement that treatment can help persons with mental illness lead normal lives, but fewer (57-3%) agreed with a statement that people are generally caring and sympathetic to persons with mental illness. Responses to these questions differed by age, sex, race/ ethnicity, and education level. Although most adults with mental health symptoms (J7.&%) agreed that treatment can help persons with mental illness lead normal lives, fewer persons with symptoms (24.6%) believed that people are caring and sympathetic to persons with mental illness. This report provides the first state-specific estimates of these attitudes and provides a baseline for monitoring trends. Initiatives that can educate the public about how to support persons with mental illness and local programs and media support to decrease negative stereotypes of mental illness can reduce barriers for those seeking or receiving treatment for mental illness (2,3).
To measure attitudes about mental illness through BRFSS and other surveys, the Substance Abuse and Mental Health Services Administration (SAMHSA) and CDC collaborated in 2005 to develop brief questions suitable for surveillance (4). BRFSS is an ongoing, state-based, random-digit-dialed telephone survey of the noninstimtionalized civilian population aged >1 8 years.* With SAMHSA and CDC support, 35 states, DC, and Puerto Rico questioned survey respondents to the 2007 BRFSS about mental illness. Questions included the Kessler-6 scale of serious psychological distress (S), frequent mental distress, one question about current treatment for an emotional problem, and two attitudinal questions.
The Kessler 6-scale asks respondents how often in the past 30 days they felt six symptoms of mental illness (i.e., feeling nervous, depressed, hopeless, restless, like a failure, like everything was an effort). Each item is scored on a 5-point scale indicating frequency, ranging from 0 (none of the time) to 4 (all of the time), and summed (score range: 0-24). Respondents scoring 13 or more on this scale were classified as having serious psychological distress (S). Frequent mental distress was measured with the question, "For how many days in the past 30 days was your mental health (due to stress, depression, or problems with emotions) not good?" Respondents reporting 14 or more poor mental health days were identified as having frequent mental distress. To determine current treatment for an emotional problem, survey participants were asked, "Are you now taking medicine or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem?"
Attitudes were assessed by asking respondents to indicate their level of agreement with two statements. The first statement assessed attitude on the effectiveness of treatment: "Treatment can help people with mental illness lead normal lives." The second statement assessed the respondent's perception of others' attitudes toward persons with mental illness: "People are generally caring and sympathetic to people with mental illness."' Before inclusion in BRFSS, cognitive testing in a sample of the general population confirmed that adults understood these questions as intended. For example, respondents suggested that "normal lives" meant "being able to do everyday things, like going to the grocery store, paying bills, things that you have to do to live." The question about attitudes toward treatment also demonstrated acceptable construct validity with expectations regarding mental illness recovery.
Data were weighted to estimate population parameters. CDC used statistical software to calculate unadjusted and adjusted proportions (adjusted for sex, age group, racial/ethnic group, education, and household income) of agreement by state and by serious psychological distress, frequent mental distress, and mental health treatment, and to account for the complex BRFSS survey design. After adjustment, CDC examined differences in proportions across agreement categories for both questions by serious psychological distress, frequent mental distress, and mental health treatment status. The analyses excluded persons who responded "did not know" or "refused" to answer the questions.* The sample size included 202,065 adults. Among the 35 states, DC, and Puerto Rico, the median Council of American Survey Research Organization (CASRO) response rate was 51% and the CASRO cooperation rate was 71.4%.'
Most adults agreed, either strongly (62.8%) or slightly (25.8%), that treatment could help persons with mental illness lead normal lives, but responses varied by states (Table 1). The highest percentages of strongly agreeing with this statement were in Connecticut, DC, Louisiana, Oregon, Vermont, Virginia, and Washington; the lowest was in Puerto Rico (Figure). Proportions for neither agree nor disagree ranged from 0.6% (Iowa) to 9.2% (Puerto Rico). Younger adults, men, persons other than white non-Hispanics, and persons at lower education levels were less likely to agree strongly with this statement (Table 2).
In contrast with the statement about treatment, a lower proportion of adults agreed, either strongly (22.3%) or slightly (35.0%), with the statement that people are caring and sympathetic to persons with mental illness (Table 3). The highest percentages of strongly agreeing with this statement occurred in Hawaii, Louisiana, Mississippi, Oklahoma, Nevada, and New Mexico. The lowest was in Puerto Rico. Adults aged 25-54 years, women, white nonHispanics and black non-Hispanics, and college graduates were less likely to agree with this statement (Table 2).
Approximately 4.0% of adults were classified with serious psychological distress, 10.0% were classified with frequent mental distress, and 10.8% reported receiving treatment for an emotional problem. Although most adults with mental health symptoms (77-6%) agreed strongly or slightly that treatment can help persons with mental illness lead normal lives, about 17.8% disagreed (Table 2). Fewer respondents with mental health symptoms (24.6%) agreed strongly or slightly that people are generally caring and sympathetic to persons with mental illness than those without such distress or treatment (Table 2).
This is the first state-specific study of attitudes toward mental illness treatment and empathy toward persons with mental illness. The study sought to assess attitudes related to the course of mental illness (i.e., treatment prognosis and possibility of recovery; and perception of supportive behaviors) that might directly influence seeking treatment or recovery and might reflect stigmatizing attitudes amenable to public health intervention. In the 37 jurisdictions surveyed, most adults believed in the effectiveness of mental illness treatment, but fewer agreed that people are caring and sympathetic toward persons with mental illness. These results have public health implications because adverse attitudes about mental illness can lead to stigmatization of persons with mental illness. In addition, the results have implications for mental health treatment because adults who do not believe in the effectiveness of mental illness treatment might be less likely to seek treatment when needed. Also, persons with mental health symptoms who believe that others are not caring and sympathetic toward persons with mental illness might be less likely to disclose mental health problems to friends, family members, colleagues, or other persons who could help.
Some of the adverse attitudes indicated in this report might be caused by stigma experienced by some respondents (e.g., those with mental health problems who received less support at work or at home or who experienced exclusion from activities) (6). Respondents who perceived adverse attitudes about empathy in other persons also might have had less contact with persons with mental illness, or also might harbor misconceptions about the risks associated with mental illness symptoms (7).
Although the study did not include all 50 states and U.S. territories, state-to-state differences were noted, but no clear regional patterns emerged on the attitudes studied. Differences might have resulted from culture and the social environment (e.g., norms, customs, language, lifestyle, and degree of acculturation), differences in how mental health is portrayed in various media, and differences in awareness of and access to mental health treatment. Geographic variability in attitudes toward mental illness and its causes should be a topic of further study.
Attitudes toward persons with mental illness appear to be improving in die United States. One study determined that in 2006, compared with previous decades since the 1950s, more U.S. adults believed that mental health problems could improve with treatment (8). The large proportion of adults with positive attitudes toward mental illness treatment in the United States (and in the 37 jurisdictions studied for this report) might result from antistigma campaigns, and greater attention, awareness, and understanding of mental health (9).
One result from the analysis presented in this report was the varying attitudes by education level. For example, adults with greater education were more likely to agree strongly that mental health treatment can help persons with mental illness lead normal lives but were less likely to agree strongly that people can be caring and sympathetic to persons with mental illness. In one study, among some professionals, more knowledge and contact with persons with mental illness was associated with more stigmatizing attitudes (10). Another possibility is that these adults might have experienced less supportive behaviors associated with mental illness (i.e., feel stigmatized) and thus were more likely to report negative attitudes compared with other groups.
The findings in this report are subject to at least four limitations. First, BRFSS surveys include only noninstitutionalized adults with telephones. Persons in institutions and in households without telephones are excluded, and this population might include a higher proportion of persons with mental health symptoms. Second, because states commonly use only English- or Spanish-language surveys, persons who speak other primary languages are excluded, which could affect race- and ethnicity-specific results. Third, because these data are not nationally representative, no conclusions can be drawn about the entire U.S. population. Finally, the question on caring and sympathy requires further validation in terms of understanding its association with other mental health attitudinal measures (4).
Persons with mental illness generally are able to live successful, full lives, particularly if they receive proper treatment and support. To reduce the effects of stigma, public health and mental health agencies can implement local activities to reduce negative attitudes about mental illness (3). Because the media can frame public opinion, they can be important partners in this and in promoting accounts of mental illness recovery (2). Public educational resources, such as those available on SAMHSA's "What a difference a friend makes" Internet site,** also can reduce negative attitudes toward mental illness by providing information about mental illness and its treatment, and help persons learn how to reassure, be friends with, and accept persons who seek or receive treatment for mental illness.
* Additional information available at http://www.cdc.gov/brfss.
1 These questions were modified from the 2002 National Scottish Survey of Public Attitudes to Mental Health, Well Being and Mental Health Problems, included in more recent versions of the survey available at http://www.scotland.gov.uk/publications/2009/09/15120l47/10.
§ For each question, approximately 2% of respondents answered "did not know" and approximately 0.3% of respondents refused to answer each question.
¶ The response rate is the percentage of persons who completed interviews among all eligible persons, including those who were not successfully contacted, lhe cooperation rate is the percentage of persons who completed interviews among all eligible persons who were contacted. Rates are available at http://ftp.cdc.gov/pub/data/ brfss/2007summaryda taqualityreport.pdf.
** Available at http://www.whatadirTerence.samhsa.gov.
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R Manderscheid, PhD, National Assoc of County Behavioral Health and Developmental Disability Directors. P Delvecchio, MSW, C Marshall, Center for Mental Health Svcs, Substance Abuse and Mental Health Svcs Admin. RG Palpant, MS, J Bigham, TH Bornemann, EdD, Carter Center Mental Health Program. R Kobau, MPH, MAPP, M Zack, MD, G Langmaid, W Thompson, PhD, D Lubar, MSW, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC