Stigma and disclosure of mental health conditions Foteini Tseliou

Background People with mental ill-health experience: symptom-related negative life events affecting quality of life negative attitudes & behaviours that the wider society holds about mental illness. Stigma: result of the complex interplay of cognitive, affective & behavioural features expressed through social interactions can act as a chronic environmental stressor.

Background Mentally-ill label: still considered a socially stigmatizing state, leading to discrimination against those affected linked with adversity, mental distress & suicidal behaviour linked to diagnostic overshadowing (physical health of people with mental illness is overlooked). Significant proportion of mentally-ill people delay contacting specialised services, remain untreated or present later, leading to poor long-term outcomes. Despite mental illness being common….

Background Concealment of mental ill-health has also been linked to: health status: those unable to work due to permanent ill-health more likely to report it (Parson’s sick role) ethnicity: minorities less likely to seek help structural barriers: rurality and access to services area-level effects: level of area deprivation devastating effect of stigma on social status. Despite mental illness being common….

Limitations of previous studies Research to date is limited by methodological issues. Uncertainty about level & variation of perceived stigma. Limitations include: Small selective clinical samples Factors examined in isolation e.g. gender differences Validity issues (use of vignettes or attitude surveys) Generalisability issues

Aims The main aims of this study were: to investigate population characteristics that might affect disclosure rates of mental ill-health; to assess perceived stigma through the comparison of a self- reported mental health measure and valid medication records.

Methodology Record-linkage study of the 2011 Northern Ireland Census returns and a centralised prescribing database. 286,717 NILS members aged 25-74 years and not living in institutionalised settings at the 2011 NI Census. 2011 NI Census Demography: age; sex; marital status; ethnicity; education Household: car availability; housing tenure; ses classification Area factors: urbanicity; area deprivation Chronic conditions: mental health, breathing difficulty Controlling for age; sex; marital status; ethnicity; education; car availability; housing tenure; economic activity; urbanicity; area deprivation

Methodology Chronic ill-health assessed through: Census self-reported chronic health question: “Do you have any of the following conditions which have lasted, or are expected to last, at least 12 months?” respondents who stated having “an emotional, psychological or mental health condition (such as depression or schizophrenia)” comparison: “respiratory or breathing difficulties such as asthma”.

Methodology linked to regular uptake of medication in the 6 months before the Census (using Health & Care Number): medication prescribed by a general practitioner & dispensed from community pharmacies collated centrally British National Formulary (BNF) categories (standard UK referencing system) four classes of psychotropic medication: anxiolytics and antidepressants (BNF categories 4.1.2 & 4.1.3), anti-psychotic medication (oral & depot, BNF categories 4.2.1 & 4.2.2); and anti-mania medication (BNF categories 4.2.3); respiratory medications (BNF Chapter 3, except antihistamines).

Results Over 3% of the population was in receipt of psychotropic medication. Being in receipt of psychotropic medication associated with: female gender, middle-age, white ethnic background, low educational attainment and poor socio-economic status, both at household & area level. *ses classification; urbanicity didn’t show significant variation and were not included for the figure’s clarity- will be in publication Controlling for: sex; age; marital status; ethnicity; education; car availability; housing tenure; ses classification; urbanicity; area deprivation

Results Amongst those receiving psychotropic medication, disclosure rates varied by a number of characteristics. Amongst those receiving psychotropic medication, being: separated/divorced/ widowed, routine jobs and renters was linked to higher disclosure rates + surprisingly women were less likely to disclose mental ill-health *age; ethnicity; education; urbanicity, area deprivation showed no significant variation Controlling for: sex; age; marital status; ethnicity; education; car availability; housing tenure; ses classification; urbanicity; area deprivation

Results In comparison, no such socio-demographic variations were observed among those in receipt of respiratory medication. *although the link with tenure was still noted, this could be linked to household deprivation and poorer physical health including breathing conditions Controlling for: sex; age; marital status; ethnicity; education; car availability; housing tenure; ses classification; urbanicity; area deprivation

Results Approximately half of the individuals regularly taking psychotropic medication disclosed mental ill-health. Medication type Those taking regular medications N (%) Those self-reporting condition in the Census N (%) Antidepressants 6,822 (2.4) 3,355 (49.2) Anxiolytics 2,682 (0.9) 1,313 (49.0) Antipsychotics 1,226 (0.4) 895 (73.0) Anti-mania 195 (0.1) 153 (78.5)   All psychotropic medication 9,417 (3.3) 4,699 (49.9) Respiratory medicine 2,401 (0.8) 1,918 (79.9) *Highest rates observed for antidepressants (2.4%), followed by anxiolytics (0.9%) and antipsychotics (0.4%). … ranging from 49% for antidepressants/ anxiolytics to 73% for antipsychotics. *highest disclosure rate observed for physical health as assessed by respiratory medication uptake

Discussion There was a mismatch between being in receipt of regular psychotropic medication and reporting poor mental health. Stigma can play a role at all stages of health behaviour: from disease recognition through to help-seeking. It is possible that distinct socio-demographic factors operate at these different levels Potentially explaining surprising findings e.g. higher rates for men who have overcome initial reluctance to disclose. *though men were less likely to receive medication- smaller group than women *perhaps those on medication differ

Discussion Public perception of severity might affect reported rates of mental ill-health: variation between different mental health conditions, with higher rates for more severe conditions. Stigma still is a major limitation in: help-seeking behaviours the assessment and treatment of mental ill-health also linked to: potential reluctance to present to a general practitioner or maintain contact with mental health services.

Methodological issues Assessing mental health amongst people currently being prescribed medication: likely to represent more severe cases that they were diagnosed and receiving treatment non-adherence to medication can be prescribed for other non-psychiatric conditions e.g. pain. Less generalizable to those patients not taking medications. Census returns: self-reported; concealment; form complexity.

Research & policy implications This study explored disclosure rates by type of mental health condition as assessed by medication prescribed, and allowed the comparison between mental disorders. Addressing internalised stigma along with medication stigma would be a major aspect in the implementation of anti-stigma campaigns. Further work needed on low utilization and knowledge/ negative experiences from mental health services.

Acknowledgements The help provided by the staff of the Northern Ireland Longitudinal Study (NILS) and the NILS Research Support Unit is acknowledged. The NILS is funded by the Health and Social Care Research and Development Division of the Public Health Agency (HSC R&D Division) and NISRA. The NILS-RSU is funded by the ESRC and the Northern Ireland Government. The authors alone are responsible for the interpretation of the data and any views or opinions presented are solely those of the author and do not necessarily represent those of NISRA/NILS.

Email: f.tseliou@qub.ac.uk Thank you for your time! Email: f.tseliou@qub.ac.uk