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The relationship between mental health literacy regarding schizophrenia and psychiatric stigma in the Republic of Ireland Article in Journal of Mental Health · October 2015 DOI: 10.3109/09638237.2015.1057327

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The relationship between mental health literacy regarding schizophrenia and psychiatric stigma in the Republic of Ireland Donal O’Keeffe, Niall Turner, Sharon Foley, Elizabeth Lawlor, Anthony Kinsella, Eadbhard O'Callaghan & Mary Clarke To cite this article: Donal O’Keeffe, Niall Turner, Sharon Foley, Elizabeth Lawlor, Anthony Kinsella, Eadbhard O'Callaghan & Mary Clarke (2015): The relationship between mental health literacy regarding schizophrenia and psychiatric stigma in the Republic of Ireland, Journal of Mental Health, DOI: 10.3109/09638237.2015.1057327 To link to this article: http://dx.doi.org/10.3109/09638237.2015.1057327

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Date: 21 October 2015, At: 03:09

http://tandfonline.com/ijmh ISSN: 0963-8237 (print), 1360-0567 (electronic) J Ment Health, Early Online: 1–9 ! 2015 Taylor & Francis Group, LLC. DOI: 10.3109/09638237.2015.1057327

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The relationship between mental health literacy regarding schizophrenia and psychiatric stigma in the Republic of Ireland Donal O’Keeffe1, Niall Turner2, Sharon Foley3, Elizabeth Lawlor1, Anthony Kinsella4, Eadbhard O’Callaghan1y, and Mary Clarke1 1

DETECT Early Intervention in Psychosis Service, Blackrock, Dublin, Ireland, 2Cluain Mhuire Family Centre, Blackrock, Dublin, Ireland, 3Early Psychosis Service, Metro South Mental Health, Australia, Macgregor, Australia, and 4Molecular and Cellular Therapeutics Department, Royal College of Surgeons in Ireland, Dublin, Ireland Abstract

Keywords

Background: There is an unclear relationship between mental health literacy (MHL) and psychiatric stigma. MHL is associated with both positive and negative attitudes to mental illness. To our knowledge, no published peer reviewed study has examined this relationship in the Republic of Ireland. Aims: This study was conducted to assess MHL regarding schizophrenia and the degree of psychiatric stigma displayed by the general public in the Republic of Ireland. Method: A face-to-face in-home omnibus survey was conducted with a representative sample of residents of the Republic of Ireland. Participants (N ¼ 1001) were presented with a vignette depicting schizophrenia and were asked questions to determine their ability to recognise the condition and to ascertain their attitudes towards schizophrenia and mental illness. Results: Among the participants, 34.1% correctly identified schizophrenia. Higher age, higher socioeconomic status, and an urban geographic location predicted identification. Those who did not correctly identify schizophrenia were significantly more optimistic about recovery and perceived people with schizophrenia as less dangerous. However, only the relationship with perceived dangerousness was considered robust. Conclusions: Participants with higher MHL displayed more negative attitudes to mental illness. Findings have implications internationally for MHL and anti-stigma campaigns.

Mental health literacy, recovery optimism, schizophrenia, stigma, violence

Introduction Mental health literacy (MHL) is defined as ‘‘knowledge and beliefs about mental disorders which aid their recognition, management or prevention’’ (Jorm et al., 1997, p. 182). It comprises awareness of how to access mental health information; the ability to recognise disorders; attitudes which aid recognition and appropriate help seeking; knowledge and beliefs about risk factors and causes of mental disorders; and awareness of the range of treatments available. Low levels of MHL can be a barrier to seeking treatment for mental illness, decreasing willingness to seek professional help when needed. An inability to recognise disorders can lead to inappropriate help seeking and delays in seeking early interventions (Jorm, 2000). From a provider perspective, MHL can determine whether or not a person receives evidence based treatment and whether or not they adhere to this treatment. MHL can influence the success of early y

Deceased Correspondence: Donal O’Keeffe, DETECT Early Intervention in Psychosis Service, Avila House, Block 5, Blackrock Business Park, Blackrock, Dublin, Ireland. Tel: +353 1 279 1700. Fax: +353 1 279 1799. E-mail: [email protected]

History Received 16 December 2014 Revised 16 March 2015 Accepted 12 May 2015 Published online 6 October 2015

detection programmes to identify mental illness in a population and therefore is a prerequisite for early recognition and intervention (Jorm et al., 2006b; Lauber et al., 2005). Psychiatric stigma may prevent people with psychiatric disabilities entering relationships, employment and housing (Amering and Schmolke, 2009). Internalised stigma has a negative relationship with hope, self-esteem, empowerment, and treatment adherence. It is positively correlated with psychiatric symptom severity, impedes mental health service utilisation, and is a significant barrier to help seeking, community integration, and recovery (Clement et al., 2015; Livingston & Boyd, 2010; Satcher, 2000). There is an unclear relationship between MHL and psychiatric stigma; the literature is conflicting. Research has demonstrated that MHL interventions can reduce stigma, and studies have found that those with more knowledge of mental illness are less likely to hold stigmatising attitudes (Brockington et al., 1993; Holmes et al., 1999; Kitchener & Jorm, 2006; Roman & Floyd, 1981; Thornton & Wahl, 1996). However, other studies have concluded that having the knowledge to be able to label someone as mentally ill is associated with increased stigma (Angermeyer & Matschinger, 2004; Hengartner et al., 2013; Martin et al., 2000; Peluso & Blay, 2009).


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D. O’Keeffe et al.

Recognition of mental disorders among the general public varies across countries and types of disorder. Under recognition is common (Jorm, 2012). However, improvements over time in schizophrenia recognition have been identified in Australian research (Jorm et al., 2006b; Reavley & Jorm, 2012). In the Republic of Ireland, two peer reviewed studies have examined general public MHL regarding schizophrenia. The first reported on MHL among a non-representative population sample of Irish internet users; it found considerable levels of MHL: 93% recognised schizophrenia (Lawlor et al., 2008). However, this study was potentially confounded by participants having internet access while participating. The second tested the effect of a television soap opera storyline on MHL. The authors found a low level of MHL: 34.6% of soap opera viewers and 35.1% of non-viewers identified schizophrenia (Turner et al., 2013). Neither paper, nor any other published peer reviewed study to our knowledge, has examined the relationship between MHL and psychiatric stigma in the Republic of Ireland. The social rejection of people with mental illness has remained stable over the past 20 years. While MHL has increased, negative attitudes to mental illness have not improved and attitudes to schizophrenia have worsened (Schomerus et al., 2012). People with psychiatric disabilities are frequently viewed as in need of help, dependent on others, unpredictable, violent, and dangerous; those diagnosed with schizophrenia and alcoholism being seen as the most dangerous (Angermeyer and Dietrich, 2006). Research has consistently shown that schizophrenia elicits more negative public beliefs and attitudes and more pessimistic views on prognosis than depression (Ozmen et al., 2008). This article reports on the findings of a secondary analysis of the baseline data of a soap opera intervention study (Turner et al., 2013). As duration of untreated psychosis influences the outcome of schizophrenia (Clarke et al., 2006; Marshall et al., 2005) and MHL can determine how early mental illness is identified and treated (Amering & Schmolke, 2009; Lauber et al., 2005) investigating general public MHL is of value. Furthermore, considering the impact of stigma on recovery, an examination of the degree to which the public hold stigmatising attitudes towards people with mental illness is paramount. We aimed to assess MHL regarding schizophrenia and the degree of psychiatric stigma displayed by the general public in the Republic of Ireland. We examined (i) the ability to identify schizophrenia; (ii) the perception of the need for professional help, the type of help needed, the perceived urgency of the need for help; (iii) the degree of recovery optimism in schizophrenia; (iv) the anticipated propensity for harm or violence associated with schizophrenia; and (v) the degree of stigma directed towards mental illness.

Method A quantitative cross-sectional omnibus survey design was used. As the research involved the use of non-identifiable information, a waiver for the study was granted by the Saint John of God Hospitaller Ministries Provincial Ethics Committee. Informed consent was obtained from all participants. In 2007, a market research company was commissioned

J Ment Health, Early Online: 1–9

to conduct a face-to-face in-home national omnibus survey. Participants were a representative sample of residents of the Republic of Ireland aged 15 (N ¼ 1001); its capital Dublin and four provinces Ulster (North), Munster (South), Leinster (East) and Connacht (West). Sampling points in the Dublin region were exclusively urban (U) and those in the other regions were largely rural (R). Interviews were conducted at 64 sampling points, representative of the size and spread of urban and rural localities nationwide. Interlocking quotas based on the 2006 population census were used for age, gender, socioeconomic status, and geographic location. After completing a demographic profile, participants were presented with a vignette depicting the symptoms of schizophrenia and asked 16 questions. This vignette was used in two earlier studies (Lauber et al., 2003; Lawlor et al., 2008). We did not obtain overall response rate data as it is not standard practice, of the market research company employed, to collect this data in quota-based omnibus surveys. Response rate was recorded at a question level. Four hundred twelve of 1001 participants (41.2%) partially completed the survey; 589/1001 participants (58.8%) fully completed the survey answering all questions. No information on risk profile, course of treatment or outcome was provided. Questions 1–4 measured MHL. Schizophrenia, paranoid schizophrenia, psychosis, and psychotic were all accepted as correct recognition of schizophrenia. Questions 5–16 assessed psychiatric stigma. Questions 5–10 and 16 were developed for this study. Questions 5–8 gauged the perceived likelihood of common aspects of recovery occurring in schizophrenia: involvement in family life, (re)gaining employment, developing close relationships, and achieving normality. Questions 9–10 measured respondents’ perception of the level of risk people with schizophrenia pose to others and to themselves. Questions 11–15 were adapted from the Perceived Devaluation and Discrimination Scale developed by Link and associates (2001). We made word changes to all scale items, we changed: (i) ‘‘most people’’ to ‘‘I’’ to ensure that respondents gave their own personal stance rather than what they thought other people would do; (ii) ‘‘psychiatric’’ to ‘‘mental health’’ to use the more common term in Ireland; and (iii) ‘‘psychiatric hospital’’ to ‘‘mental health services’’ to reflect the community model of mental health treatment. Question 16 examined willingness to live close to someone with a mental illness. Statistical analysis Data was analysed in SPSS 21 (Chicago, IL). Our analysis examined relationships between demographics, MHL, and psychiatric stigma. Demographic categories and schizophrenia recognition groups were compared using parametric and non-parametric tests. With large samples, small differences between groups can be statistically significant. To address this, our reporting focused on significant findings that were deemed robust; findings with an effect size Cohen’s definition of ‘small’ (i.e. phi coefficient 0.1; Cramer’s V 0.1 [df smallest side of contingency table ¼ 1]; r 0.1; d 0.2; and eta squared 0.01) (Cohen, 1992). This approach has been previously adopted by other authors (Reavley & Jorm, 2012). Logistic regression was used to test a model to predict schizophrenia recognition. Principal

Schizophrenia MHL and stigma in Ireland

DOI: 10.3109/09638237.2015.1057327

Components Analysis was used to reduce data in order to form coherent scales from questions measuring psychiatric stigma.

Results


Recognition of schizophrenia Chi-square tests for independence were used to compare baseline characteristics of participants who correctly recognised schizophrenia and those who did not. Results are displayed in Table 1. 2006 population census data are included in Table 1 to demonstrate sample representativeness (Central Statistics Office, 2007). The following labels were used by participants to describe the vignette: depression (19.9%); nervous breakdown (10.7%); schizophrenia/paranoid schizophrenia/psychosis/psychotic (34.1%); mental illness (13.3%); psychological/emotional problems (4.2%); paranoia (6.3%); stress (2.0%); ‘‘has a problem’’ (4.1%); cancer (0.3%); other (1.9%). 3.3% of participants indicated that they did not know how to describe the experience depicted in the vignette.

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Three hundred forty-one of 1001 participants (34.1%) correctly identified schizophrenia from the vignette. Robust significant relationships were found between correct recognition and age, occupational status, socioeconomic status, education, and geographic location. Results show a consistent increase in recognition rates up to the age of 49, then a decrease after 50. Chi-square results were used to select variables to be entered into a logistic regression model. Independent variables that had a significant relationship with schizophrenia recognition at a p50.01 level were retained for inclusion in the model. Direct logistic regression was performed to assess the impact of age, occupational status, socioeconomic status, education, and geographic location on the likelihood that participants would correctly identify schizophrenia. Correlations among these variables were investigated and no multicollinearity was identified. The full model containing all predictors was statistically significant, 2 (13, N ¼ 909) ¼ 87.53, p50.001. It explained between 9.2% (Cox and Snell R2) and 12.6% (Nagelkerke R2) of the variance in schizophrenia recognition and correctly classified 64.5 of cases.

Table 1. Comparisons of baseline characteristics by schizophrenia recognition group.

Characteristic Age in years n (%) 15–18 19–24 25–39 40–49 50–64 65 Gender n (%) Male Female Marital status n (%) Single Married Widowed/Separated/ Divorced Occupational status n (%) Working Housewife Student Other Socioeconomic status n (%) A B C1 C2 D E F Education n (%) Basic 3rd level Geographic location n (%) Dublin (U) Leinster (excluding Dublin) (R) Munster (R) Connacht/Ulster (R)

2006 population census

Correct recognition of schizophrenia

Incorrect recognition

Chi square tests of independence

(8.6) (10.8) (32.1) (17.0) (19.2) (12.4)

8 (2.3) 37 (10.9) 131 (38.4) 71 (20.8) 73 (21.4) 21 (16.9)

78 (11.8) 71 (10.8) 190 (28.8) 99 (15.0) 119 (18.0) 103 (15.6)

2 (5) ¼ 52.00 p50.001 ’ ¼ 0.23a n ¼ 1001

2 121 200 2 118 700

490 (49.0) 511 (51.0)

151 (44.3) 190 (55.7)

339 (51.4) 321 (48.6)

2 (1) ¼ 4.23 p ¼ 0.03 ’ ¼ 0.07 n ¼ 1001

1 453 200 1 565 000 357 200

389 (38.9) 515 (51.4) 97 (9.7)

114 (33.4) 191 (56.0) 36 (10.6)

275 (41.7) 324 (49.1) 61 (9.2)

2 (2) ¼ 6.41 p ¼ 0.04 ’ ¼ 0.08 n ¼ 1001

1 930 000 387 000 349 000 658 400

564 178 105 114

(56.3) (17.8) (10.5) (15.4)

224 (65.7) 54 (15.8) 23 (6.7) 40 (11.7)

340 (51.5) 124 (18.8) 82 (12.4) 114 (17.3)

2 (3) ¼ 20.52 p50.001 ’ ¼ 0.14a n ¼ 1001

Data not available

376 (37.6) 625 (62.4)

170 (49.9) 171 (50.1)

206 (31.2) 454 (68.8)

2 (1) ¼ 32.52 p50.001 ’ ¼ 0.18a n ¼ 1001

1 891 000 829 100

717 (78.9) 192 (21.1)

225 (69.7) 98 (30.3)

492 (84.0) 94 (16.0)

2 (1) ¼ 24.70 p50.001 ’ ¼ 0.17a n ¼ 909

1 187 200 1 107 947

303 (30.3) 253 (25.3)

133 (39.0) 74 (21.7)

170 (25.8) 179 (27.1)

1 173 300 771 400

254 (25.4) 119 (19.1)

83 (24.3) 51 (15.0)

171 (25.9) 140 (21.2)

2 (3) ¼ 20.48 p50.001 ’ ¼ 0.14a n ¼ 1001

15–19 290 257 20–24 342 475 25–39 373 078 40–49 576 074 50–64 654 123 65 467 926

Overall sample 86 108 321 170 192 124

A ¼ higher managerial, administrative, or professional; B ¼ intermediate managerial, administrative, or professional; C1 ¼ supervisory or clerical, junior managerial, administrative, or professional; C2 ¼ skilled manual workers; D ¼ semi and unskilled manual workers; E ¼ state pensioners or widows (no other earner), casual, or lowest grade workers. U ¼ exclusively urban; R ¼ largely rural. ’ ¼ effect size (phi coefficient or Cramer’s V). a A significant difference with an effect size Cohen’s definition of ‘‘small’’.

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Table 2. Responses to Recovery Optimism, Anticipated Propensity for Harm/Violence, and Stigma questions by negative/neutral/positive attitude. Negative attitude n (%)


Question Recovery Optimism Likelihood of participating in family life next Christmas, n ¼ 832 Likelihood of returning to work within a year, n ¼ 859 Likelihood of developing close relationships, n ¼ 860 Likelihood of living an ordinary life in the future, n ¼ 882 APHV Likelihood of doing something harmful or violent to himself, n ¼ 858 Likelihood of doing something harmful or violent to others, n ¼ 803 Stigma Agreement that using mental health services is a sign of personal failure, n ¼ 955 Willingness to accept a former mental health patient as a personal friend, n ¼ 913 Willingness to hire a former mental health patient who is psychiatrically stable to take care of one’s children, n ¼ 867 Willingness to date someone who has been hospitalised for a serious mental illness, n ¼ 901 Willingness to pass over the application of a former mental health patient in favour of another applicant, n ¼ 863 Level of comfort living close to someone who has a serious mental disorder, n ¼ 922

Only three of the independent variables made a unique statistically significant contribution to the model (age [p ¼ 0.003], socioeconomic status [p50.001], and geographic location [p50.001]). The strongest predictor of schizophrenia recognition was age. Help seeking The vast majority of participants (96.7%) believed that the person depicted in the vignette required professional help. Most felt that if they were in the situation of the person depicted, they would seek help immediately (54.5%), followed by those that felt they would get help ‘‘as soon as they thought they had a real problem’’ (31.4%). The most popular help seeking recommendation was ‘‘visit a GP’’ (58.8%), followed by ‘‘visit a psychiatrist’’ (12%), ‘‘talk to friends/ family’’ (10.8%) and ‘‘visit a counsellor’’ (5%). Few participants recommended visiting a psychologist (2.9%), going to hospital/accident and emergency services (2.4%), ringing a helpline (2.3%), and visiting a social worker (2%). Principal components analysis Twelve questions investigating attitudes to mental illness were subjected to principal components analysis (PCA). Prior to carrying out PCA, suitability of data for factor analysis was assessed. Inspection of the correlation matrix revealed the presence of many coefficients of 0.3 and above. The Kaiser– Meyer–Olkin value was 0.78, exceeding the recommended value of 0.6 and Bartlett’s Test for sphericity reached statistical significance, supporting the factorability of the correlation matrix (Kaiser, 1974). The PCA revealed the presence of four components with eigenvalues exceeding 1, explaining 30.8%, 21.8%, 10.8%, and 8.7% of the variance respectively. Using Cattell’s scree test (Cattell, 1966), it was decided to retain three components for further investigation. This decision was further supported by parallel analysis results which revealed three components with eigenvalue exceeding the corresponding criterion values for a randomly generated data matrix of the same size. The three-component

310 368 383 408

(37.3) (42.8) (44.5) (46.3)

Neutral/no opinion n (%) 131 152 172 142

(15.7) (17.7) (20.0) (16.1)

Positive attitude n (%) 391 339 305 332

(47.0) (39.5) (35.5) (37.6)

289 (33.7) 337 (42.0)

174 (20.3) 237 (29.5)

395 (46.0) 229 (28.5)

72 (7.5) 149 (16.3) 256 (29.5)

78 (8.2) 174 (19.1) 227 (26.2)

805 (84.3) 590 (64.6) 384 (44.3)

271 (30.1)

247 (27.4)

383 (42.5)

450 (52.1)

237 (27.5)

176 (20.4)

431 (46.7)

217 (23.5)

274 (29.7)

solution explained a total of 63.4% of the variance, with Component 1 contributing to 30.8%, Component 2 contributing to 21.9% and Component 3 contributing to 10.8%. To aid in the interpretation of these three components, oblimin rotation was performed. The rotated solution revealed a simple structure, with all three components showing a number of strong loadings and all variables loading on only one component. Results revealed three coherent scales: Recovery Optimism, Anticipated Propensity for Harm/Violence (APHV), and Stigma. Recovery Optimism, APHV, and Stigma Responses to Recovery Optimism, APHV and Stigma questions by attitude are shown in Table 2. Comparisons of Recovery Optimism, APHV, and Stigma scores by schizophrenia recognition group are detailed in Table 3. Significant differences were examined using the Mann–Whitney U-tests and an independent samples t-test. Recovery Optimism, APHV, and Stigma scores were compared across demographic variables using the Mann– Whitney U-tests, Kruskal–Wallis H tests, independent samples t-tests, One-way ANOVAs, and Tukey HSD tests. Results are displayed in Table 4.

Discussion We found a low schizophrenia recognition rate (34.1%), which is consistent with some studies (Jorm et al., 1997, 2006a; Reavley & Jorm, 2012), but not with others (Lauber et al., 2003; Lawlor et al., 2008). Higher age, higher socioeconomic status, and an urban geographic location predicted identification. One interpretation of these results is that individuals with these characteristics have been more exposed to education on schizophrenia. These socioeconomic status and urbanicity effects have been found by another author (Suhail, 2005). Adolescents were much less likely than other age groups to correctly identify schizophrenia, replicating a finding of Wright et al. (2005). This may be the result of adolescents lacking life experience. Few participants aged


DOI: 10.3109/09638237.2015.1057327

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Table 3. Comparisons of Recovery Optimism, Anticipated Propensity for Harm/Violence, and Stigma scores by schizophrenia recognition group.

Scale Recovery Optimism, M (SD)


Anticipated Propensity for Harm/ Violence, M (SD) Stigma, M (SD)

Correct recognition of schizophrenia

Incorrect recognition

11.12 (4.08)

11.72 (4.16)

5.59 (2.04)

6.03 (1.99)

19.33 (3.91)

19.40 (3.36)

Mann–Whitney U/ independent samples t-test U ¼ 65 029 p ¼ 0.04 r ¼ 0.08 n ¼ 780 U ¼ 66 045.5 p ¼ 0.01 r ¼ 0.10a n ¼ 798 t ¼ 0.28 p ¼ 0.78 d ¼ 0.02 n ¼ 745

d ¼ Cohen’s d; r ¼ correlation coefficient effect size. A significant difference with an effect size Cohen’s definition of ‘‘small’’.

a

65 identified schizophrenia; a finding which is consistent with previous research (Farrer et al., 2008). This may be in part due to MHL campaigns not targeting people aged 65, and this age group not having access to school mental health education programmes or certain media such as the internet (Farrer et al., 2008). No robust gender effect was found, in line with other studies (Cotton et al., 2006; Lawlor et al., 2008). Just over half of the sample acknowledged the urgency of treatment, indicating that the person depicted should seek help immediately, thereby recognising the importance of early intervention in psychosis. The majority would seek help from a GP for symptoms of schizophrenia, consistent with prior research (Clement et al., 2015; Jorm et al., 1997). This indicates that the Irish public is aware of one appropriate referral route to mental health services. In comparison with other studies, less participants recommended visiting a psychiatrist or a psychologist or talking to friends/family (Angermeyer et al., 1999; Jorm et al., 1997). Very few participants recommended going to hospital/accident and emergency services. This is of note considering that emergency services have been identified as the most common referral source for first episode psychosis patients (Anderson et al., 2010). Participants’ attitudes relating to the likelihood of recovery in schizophrenia were mixed; participants were mostly optimistic about future participation in family life, but mostly pessimistic about returning to work within a year, developing close relationships, and living an ordinary life in the future. These results suggest recovery pessimism in some life domains, despite a high long-term recovery rate identified in people with schizophrenia (Harrison et al., 2001). The highest percentages of participants did not anticipate self-harm or self-directed violence from those with schizophrenia, but anticipated harm or violence directed at others. These views are held regardless of evidence indicating that people with schizophrenia are 14 times more likely to be victims of a violent crime than to be arrested as the perpetrator of violence (Brekke et al., 2001). Although there is a modest association between violence and schizophrenia

(Fazel et al., 2009), the public may overestimate this risk due to the portrayal of schizophrenia in the media (Thornton & Wahl, 1996; Wahl et al., 1995). Levels of stigma varied depending on the question asked. Our findings mirror data confirming that desire for social distance is correlated with the closeness of the relationship in question (Angermeyer & Dietrich, 2006). The aforementioned perceived dangerousness may explain this as it appears to mediate the effect of mental illness labeling on social distance (Martin et al., 2000). Stigma was highest in the area of employment, followed by willingness to live close to someone with a mental disorder, willingness to be romantically involved with a former mental health patient, and willingness to permit childcare to be given by them. These forms of stigma are especially problematic as the recovery outcomes valued by mental health service users are something to do, somewhere to live, and someone to love (Dunn, 1999). Consistent with previous research (Angermeyer & Matschinger, 2004; Hengartner et al., 2013; Martin et al., 2000; Peluso & Blay, 2009), participants who correctly recognised schizophrenia (i.e. people with high MHL) displayed more negative attitudes to mental illness. Statistically significant relationships were found between correct recognition and (i) Recovery Optimism and (ii) APHV. However, only the association with APHV was considered robust. These relationships may be due to participants with higher MHL being more exposed to education on mental illness. If this education encouraged the adoption of biogenetic causal explanations of mental illness, it may have promoted the idea of ‘‘otherness’’, prejudice, and fear; reduced Recovery Optimism; and propagated the perception that people with psychiatric disorders are unpredictable and dangerous, resulting in a desire for social distance (Angermeyer et al., 2011; Read et al., 2006). This understanding of mental illness infers that there are permanent differences between people diagnosed with schizophrenia and those not. Educating the public to think that ‘‘mental illness is an illness like any other’’ may have the unexpected consequence of increasing stigma. If the perception is that people with schizophrenia cannot be held

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Table 4. Comparisons of Recovery Optimism, Anticipated Propensity for Harm/Violence, and Stigma scores by baseline characteristics.


Characteristic Age in years, M (SD) 15–18 19–24 25–39 40–49 50–64 65 Gender, M (SD) Male Female

Recovery Optimism

Mann–Whitney U/ Kruskal–Wallis H

8.14 (3.72) 11.55 (4.35) 11.10 (4.00) 11.18 (4.14) 11.52 (4.28) 11.42 (4.70)

H ¼ 6.84 p ¼ 0.23 n ¼ 780

11.34 (4.22) 11.08 (4.20)

U ¼ 74 475.00 p ¼ 0.64 r ¼ 0.02 n ¼ 780

6.11 (2.03) 5.68 (2.13)

10.81 (4.30) 11.37 (4.30) 11.64 (4.61)

H ¼ 4.69 p ¼ 0.10 n ¼ 780

11.38 (4.18) 11.01 (4.16) 8.00 (3.76) 11.28 (4.30)

H ¼ 6.57 p ¼ 0.09 n ¼ 780

Marital Status, M (SD) Single Married Widowed/Separated/ Divorced Occupational Status, M (SD) Working Housewife Student Other Post Hoc Tests Tukey HSD Working Student Socioeconomic Status, M (SD) A, B, C1 C2, D, E, F

11.56 (3.74) 10.98 (4.48)

U ¼ 65 327.50 p ¼ 0.01 r ¼ 0.09 n ¼ 780

Education, M (SD) Basic 3rd Level

11.06 (4.32) 11.70 (3.79)

9.26 (3.67) 11.69 (4.22)

Geographic Location, M (SD) Dublin (U) Leinster (excluding Dublin) (R) Munster (R) Connacht/Ulster(R) Post Hoc Tests Mann-Whitney U Dublin (U) Leinster (excluding Dublin) (R) Dublin (U) Munster (R)

(Md ¼ 8) (Md ¼ 14)

Dublin (U) Connacht/Ulster (R)

(Md ¼ 8) (Md ¼ 14)

Stigma

Independent samples t-test/ one-way ANOVA

(4.40) (3.73) (3.62) (3.30) (4.00) (3.56)

F ¼ 1.49 p ¼ 0.19 es ¼ 0.01 n ¼ 745

U ¼ 72 026.50 p ¼ 0.02 r ¼ 0.08 n ¼ 798

19.03 (3.69) 19.62 (3.73)

t ¼ 1.17 p ¼ 0.24 d ¼ 0.16 n ¼ 745

5.68 (2.27) 6.00 (1.92) 6.05 (2.34)

H ¼ 2.42 p ¼ 0.30 n ¼ 798

18.86 (4.05) 19.59 (3.44) 19.54 (3.87)

F ¼ 1.49 p ¼ 0.23 es ¼ 0.004 n ¼ 745

5.92 5.96 5.07 5.84

H ¼ 6.57 p ¼ 0.09 n ¼ 798

19.58 19.33 13.93 19.25

F ¼ 4.35 p ¼ .005 es ¼ 0.02a n ¼ 745

5.21 5.88 5.79 5.87 5.96 6.31

(2.00) (2.41) (2.10) (1.89) (1.96) (2.33)

(2.01) (2.02) (2.38) (2.03)

H ¼ 1.91 p ¼ 0.86 n ¼ 798

15.14 19.41 19.40 19.35 19.77 19.20

(3.66) (3.43) (3.56) (3.64)

p ¼ 0.002

(M ¼ 19.61, SD ¼ 3.54) (M ¼ 17.94, SD ¼ 3.87)

5.91 (2.00) 5.88 (2.16)

U ¼ 71 433.00 p ¼ 0.22 r ¼ 0.04 n ¼ 798

19.51 (3.66) 19.21 (3.76)

t ¼ 0.36 p ¼ 0.72 d ¼ 0.08 n ¼ 745

U ¼ 414 411.50 p ¼ 0.08 r ¼ 0.07 n ¼ 723

5.85 (2.12) 6.05 (2.20)

U ¼ 41 795.00 p ¼ 0.10 r ¼ 0.006 n ¼ 738

19.41 (3.78) 19.06 (3.50)

t ¼ 1.15 p ¼ 0.25 d ¼ 0.10 n ¼ 692

H ¼ 124.75 p50.001 n ¼ 780

5.04 (1.98) 6.61 (1.99)

H ¼ 57.35 p50.001 n ¼ 798

18.93 (4.40) 19.28 (3.11)

F ¼ 3.28 p ¼ 0.02 es ¼ 0.02a n ¼ 745

13.12 (4.08) 12.49 (3.75)

(Md ¼ 8) (Md ¼ 13.5)

APHV

Mann–Whitney U/ Kruskal–Wallis H

6.14 (2.13) 6.36 (1.83) U ¼ 14 418.5 z ¼ 8.25 p50.001 r ¼ 0.38a U ¼ 11 823 z ¼ 9.44 p50.001 r ¼ 0.45a U ¼ 8709, z ¼ 7.95 p50.001 r ¼ 0.4a

(Md ¼ 5) (Md ¼ 6) (Md ¼ 5) (Md ¼ 6) (Md ¼ 5) (Md ¼ 6)

20.05 (3.22) 19.44 (3.40) U ¼ 15 685 z ¼ 6.58 p50.001 r ¼ 0.31a U ¼ 18 838 z ¼ 5.59 p50.001 r ¼ 0.45a U ¼ 1448.6 z ¼ 4.94 p50.001 r ¼ 0.26a

(M ¼ 18.97, SD ¼ 4.24) (M ¼ 20.10, SD ¼ 3.22)

APHV ¼Anticipated Propensity for Harm/Violence. A ¼ higher managerial, administrative, or professional; B ¼ intermediate managerial, administrative, or professional; C1 ¼ supervisory or clerical, junior managerial, administrative, or professional; C2 ¼ skilled manual workers; D ¼ semi and unskilled manual workers; E ¼ state pensioners or widows (no other earner), casual or lowest grade workers. U ¼ exclusively urban; R ¼ largely rural. d ¼ Cohen’s d; r ¼ correlation coefficient effect size; es ¼ eta squared. a A significant difference with an effect size Cohen’s definition of ‘‘small’’.


DOI: 10.3109/09638237.2015.1057327

responsible for their behaviour (due to their illness being caused by biology and genetics), then they may be considered a risk (Angermeyer et al., 2011; Read et al., 2006). This assumption flies in the face of the Recovery Model where people with mental illness are viewed as active agents in their own lives, capable of self-management, directing their recovery, taking ownership of their illness, and assuming responsibility for their behaviour (Shepherd et al., 2008). Another interpretation of our findings is that the negative relationship between MHL and Recovery Optimism may reflect people with high MHL being more aware of the impact of schizophrenia, the life challenges that come with recovery, and the likelihood of negative outcomes in mental illness (i.e. unemployment, isolation, and singlehood) (Sheridan et al., 2015). However, as the association between correct identification of schizophrenia and Recovery Optimism is weak, caution should be applied to its interpretation. Another explanation for our results concerns the positive relationship between education and media consumption (Roe, 2000). If the mental health literate, highly educated individual is more exposed to the media than the rest of the population, then they may be more likely to receive the message that people with schizophrenia are unpredictable and violent. Moreover, the similarity between the words ‘‘psychotic’’ and ‘‘psychopathic’’ and the common misconception that schizophrenia infers a split personality further disseminates this negative stereotype. In examining the relationship between geographic location and Recovery Optimism, APHV, and Stigma, robust effects were found. Participants living in the Dublin region were significantly more likely than the rest of the country to be pessimistic regarding recovery in schizophrenia, to expect harm or violence from people with schizophrenia, and to stigmatize people with mental health difficulties. This may be an urbanicity effect as the sampling points in the Dublin region were exclusively urban and those in the other regions of the country were largely rural. Ethiopian, American, and Polish research has suggested urban residents are more likely to perceive psychiatric stigma as a significant problem (Shibre et al., 2001), to report experiences of stigma as a barrier to treatment (Kessler et al., 2001), and to believe that mental illness results in exclusion from the labour market (Cechnicki et al., 2011). Participants living in Dublin are likely to experience higher levels of exposure to schizophrenia than other regions, as incidence of schizophrenia is associated with urbanicity (Kelly et al., 2010). While research has found that contact based interventions reduce psychiatric stigma (Corrigan et al., 2012), other studies have shown that natural interpersonal contact with people with mental illness increases stigma and desire for social distance (Eisenberg et al., 2012; Graves et al., 2011). The type and quality of exposure may be relevant (Couture & Penn, 2003). It is likely that the public’s experience of contact with people with schizophrenia is dominated by those who are actively symptomatic as they cannot hide their illness in the way that someone who is recovered could. Due to the high levels of stigma associated with schizophrenia (Ozmen et al., 2008), not self-disclosing a schizophrenia diagnosis acts as a protection mechanism, minimizing the risk of discrimination, pity, ostracism, and anxiety and stress due to monitoring


7

following disclosure (Corrigan & Lundin, 2001). If highly functioning well-recovered individuals do not speak about their illness and recovery, the general public never perceives their contact with them as contact with schizophrenia and thus forms an understanding of schizophrenia that is skewed towards chronicity and long-term impairment. Their exposure experience, therefore, may not be representative of the heterogeneity in schizophrenia outcomes. Our results confirmed a robust significant association between occupational status and stigma. Students displayed significantly higher levels of stigma than those in employment. 93.3% of students were either adolescents (15–18 years: 73.3%) or young adults (18–25 years: 20%). The attitudes of these students to mental illness are likely to be rapidly evolving due to the developmental processes they are undergoing. They are just beginning to learn how to recognise symptoms (Eisenberg et al., 2009). Moreover, the prevalence of serious mental illness is lower for students than for the general population resulting in lower exposure rates (Blanco et al., 2008). These findings have implications for MHL and antistigma campaigns. Campaigns might consider giving particular attention to schizophrenia as our findings indicate that it is not easily recognised by the public and particularly stigmatised. To address the lack of knowledge among people aged 18 and 65, those living outside of Dublin, individuals without third-level education, and people of low socioeconomic status, campaigns could be made accessible to these groups. It may be beneficial to take into account the higher levels of psychiatric stigma we found among urban residents. Increasing the attention given to the biopsychosocial model and the stress-vulnerability model in education programmes may be advantageous, although a recent randomised controlled trial concluded that providing etiological explanations of any type does not reduce stigma (Schlier et al., 2014). Future anti-stigma campaigns may benefit from promoting Recovery Optimism and challenging stereotypes by disseminating statistics on recovery and the likelihood of harm or violence in schizophrenia. Other promising approaches include emphasising how symptoms of schizophrenia occur on a continuum with normal experiences and presenting simulated experiences of hallucinations (Ando et al., 2011; Wiesjahn et al., 2014). Interventions that aim to enhance MHL through education and to reduce stigma through contact with people with schizophrenia may inadvertently risk enhancing stigma. To address this, firstly, a review of the content of MHL campaigns is warranted. Secondly, antistigma campaigns could focus on contact with individuals with schizophrenia who moderately disconfirm stereotypes (Reinke et al., 2004). This study has a number of limitations. We were unable to report a response rate for our survey which limits assessments of non-response bias and sample representativeness. Responses to vignettes may not predict how a person will behave when they are exposed to schizophrenia or how they will respond to the onset of psychosis (Suhail, 2005). Research investigating actual behavior of the public towards someone identified as having schizophrenia in a naturalistic context may be of benefit. Furthermore, face to face

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interviews increase the likelihood of socially desirable responses (Bowling et al., 2005) and the help seeking behaviours people recommend to others are not necessarily the ones that they adopt for themselves (Raviv et al., 2000). Future research may wish to control for social desirability and consider alternative methods of assessing MHL.


Conclusion MHL among the population of the Republic of Ireland is low; participants displayed a poor schizophrenia recognition rate and a moderate degree of awareness of appropriate treatments. Our results suggest a complex relationship between MHL and psychiatric stigma, implying that efforts to improve MHL will not necessarily result in reducing stigma.

Acknowledgements The authors would like to acknowledge Millward Brown for data collection.

Declaration of interest The authors would like to acknowledge the Mental Health Commission of Ireland for funding the national survey.

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