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This evaluation of the Time to Change anti-stigma campaign in England represents a milestone in international stigma research. While showing some positive outcomes, the overall picture is mixed and falls short of the wholesale shift in attitudes that is needed. A new approach is proposed for the coming decades.
Summary Time to Change (TTC) is the largest-ever programme in England designed to reduce stigma and discrimination against people with mental health disorders. The TTC evaluation partner is the Institute of Psychiatry at King's College London. We give an overview of the TTC programme 2007-2011 and describe how it was evaluated, by introducing the seven interrelated papers in this supplement, which, taken together, describe a complex series of social interventions using a research design of hitherto unparalleled detail and comprehensiveness.
Background In 2006 the Shaw Trust charity found high levels of ignorance and poor preparedness to deal with mental health problems among 480 senior employers in the UK. The UK government, non-governmental organisations and Time to Change (TTC) have since provided relevant assistance to employers. Aims To examine whether there have been improvements in mental health-related knowledge, attitudes and workplace practices among British senior employers between 2006 and 2010. Method A telephone survey was conducted of senior British employers ( n = 480 in 2006 and n = 500 in 2009 and 2010). Results An increased awareness of common mental health problems was detected. Employers continued to believe that job candidates should disclose a mental health problem, but became less likely to view colleagues' attitudes as a barrier to employing someone with such a problem. Formal policies on mental health and the use of workplace accommodations became increasingly common. Conclusions These results are consistent with those of the TTC national public attitudes and the Viewpoint survey of service users between 2008 and 2010, which showed improved public attitudes to mental illness and a reduction in experiences of discrimination in employment.
Background Research suggests that levels of discrimination against people using mental health services are high; however, reports of these people's experiences are rare. Aims To determine whether the Time to Change (TTC) programme target of 5% reduction in discrimination has been achieved. Method Separate samples of people using mental health services were interviewed annually from 2008 to 2011 using the Discrimination and Stigma Scale to record instances of discrimination. Results Ninety-one per cent of participants reported one or more experiences of discrimination in 2008 compared with 88% in 2011 (z=-1.9, P =0.05). The median negative discrimination score was 40% in 2008 and 28% in 2011 (Kruskal-Wallis χ2=83.4, P < 0.001). Conclusions The proportion of participants experiencing no discrimination increased significantly over the course of TTC but by less than the initial target The overall median discrimination score fell by 11.5%. Data from 2010 and 2011 suggest that these gains may be hard to maintain during economic austerity.
Background Education Not Discrimination (END) is the component of the Time to Change programme intended to reduce mental health stigma among professionals and professional trainees. Aims To investigate the impact of the END anti-stigma programme on medical students immediately and after 6 months with regard to knowledge, attitudes, behaviour and empathy. Method A total of 1452 medical students participated in the study (intervention group n = 1066, control group n = 386). Participants completed questionnaires at baseline, and at immediate and 6-month follow-up. Groups were compared for changes in stigma outcomes. Results All measures improved in both groups, particularly among students with less knowledge and more stigmatising attitudes and intended behaviour at baseline. At immediate follow-up the intervention group demonstrated significantly greater improvements in stigma-related knowledge and reductions in stigma-related attitudes and intended behaviour, relative to the control group. At 6 months' follow-up, however, only one attitude item remained significantly better. Conclusions Although the intervention produced short-term advantage there was little evidence for its persistent effect, suggesting a need for greater integration of ongoing measures to reduce stigma into the medical curriculum.
Background Public stigma against people with mental health problems is damaging to individuals with mental illness and is associated with substantial societal burden. Aims To investigate whether public knowledge, attitudes and behaviour in relation to people with mental health problems have improved among the English population since the inception of the Time To Change programme in 2009. Method We analysed longitudinal trends in public knowledge, attitudes and behaviour between 2009 and 2012 among a nationally representative sample of English adults. Results There were improvements in intended behaviour (0.07 standard deviation units, 95% CI 0.01-0.14) and a nonsignificant trend for improvement in attitudes ( P =0.08) among the English population. There was, however, no significant improvement in knowledge or reported behaviour. Conclusions The findings provide support for effectiveness of the national Time to Change programme against stigma and discrimination in improving attitudes and intended behaviour, but not knowledge, among the public in England.
Background Evidence on the economic impact of social marketing antistigma campaigns in relation to people with mental illness is limited. Aims To describe the economic impact of the Time to Change (TTC) anti-stigma social marketing campaign, including the potential effects on the wider economy. Method Data collected for the evaluation of TTC were combined with the social marketing campaign expenditure data to investigate differences in knowledge, attitudes and behaviour in relation to campaign awareness. To evaluate the return on investment, we applied a decision model that estimated the impact on employment for people with depression. Results Based on average national social marketing campaign costs, the economic benefits outweighed costs even if the campaign resulted in only 1% more people with depression accessing services and gaining employment if they experienced a health improvement The cost per person with improved intended behaviour was at most £4 if we assume the campaign was responsible for 50% of the change. Costs associated with improved knowledge and attitudes, however, were more variable. Conclusions The findings suggest that the TTC anti-stigma social marketing campaign is a potentially cost-effective and low-cost intervention for reducing the impact of stigma on people with mental health problems.
Background Better newspaper coverage of mental health-related issues is a target for the Time to Change (TTC) anti-stigma programme in England, whose population impact may be influenced by how far concurrent media coverage perpetuates stigma and discrimination. Aims To compare English newspaper coverage of mental health-related topics each year of the TTC social marketing campaign (2009-2011) with baseline coverage in 2008. Method Content analysis was performed on articles in 27 local and national newspapers on two randomly chosen days each month. Results There was a significant increase in the proportion of anti-stigmatising articles between 2008 and 2011. There was no concomitant proportional decrease in stigmatising articles, and the contribution of mixed or neutral elements decreased. Conclusions These findings provide promising results on improvements in press reporting of mental illness during the TTC programme in 2009-2011, and a basis for guidance to newspaper journalists and editors on reporting mental illness.
The Time to Change campaign and its evaluation in this supplement are looked at from a service user's perspective. A number of achievements are applauded, but pertinent questions about the campaign analysis are raised and a qualitative evaluation is called for.
BackgroundEngland's Time To Change (TTC) social marketing campaign emphasised social contact between people with and without mental health problems to reduce stigma and discrimination.AimsWe aimed to assess the effectiveness of the mass media component and also that of the mass social contact events.MethodOnline interviews were performed before and after each burst of mass media social marketing to evaluate changes in knowledge, attitudes and behaviour and associations between campaign awareness and outcomes. Participants at social contact events were asked about the occurrence and quality of contact, attitudes, readiness to discuss mental health and intended behaviour towards people with mental health problems.ResultsPrompted campaign awareness was 38-64%. A longitudinal improvement was noted for one intended behaviour item but not for knowledge or attitudes. Campaign awareness was positively associated with greater knowledge (β = 0.80, 95% CI 0.52-1.08) and more favourable attitudes (commonality OR 1.37, 95% CI 1.10-1.70; dangerousness OR 1.41, 95% CI 1.22-1.63) and intended behaviour (β = 0.75, 95% CI 0.53-0.96). Social contact at events demonstrated a positive impact (M=2.68) v. no contact (M = 2.42) on perceived attitude change; t(211)= 3.30, P=0.001. Contact quality predicted more positive attitude change (r=0.33, P<0.01) and greater confidence to challenge stigma (r=0.38, P<0.01).ConclusionsThe favourable short-term consequences of the social marketing campaign suggest that social contact can be used by anti-stigma programmes to reduce stigma.
A new approach to understanding severe mental illnesses such as schizophrenia and affective disorders is to adopt a clinical staging model. Such a model defines the extent of the illness such that earlier and milder phenomena are distinguished from later, more impairing features. Part of the appeal of such a model is that it should have cross-diagnostic applications, but to date there has been no attempt to examine imaging or neurocognitive evidence for staging in this way. We review these two domains of study with particular focus on major depression and bipolar affective disorder. Although there is some support for the staging model in affective disorders, conclusions are limited by the large variability in the clinical samples studied, especially with regard to the presence of psychotic symptoms. We suggest that future research needs to take a transdiagnostic and longitudinal approach.
The study of age at onset of mental health disorders is technically and conceptually difficult. It is important to consider these age distributions in order to understand causes and mechanisms of illness and to intervene at an appropriate juncture for primary and secondary prevention. This article reviews some of the approaches to studying age at onset, sets out the evidence to support the assertion that adult mental disorders begin in adolescence, and finds that perhaps half of all adult mental health disorders have begun by the teenage years. The paper then discusses whether this fits what is known about the developmental neurobiology of the brain and introduces the implications for mental health services.
Despite the evidence showing that young people aged 12-25 years have the highest incidence and prevalence of mental illness across the lifespan, and bear a disproportionate share of the burden of disease associated with mental disorder, their access to mental health services is the poorest of all age groups. A major factor contributing to this poor access is the current design of our mental healthcare system, which is manifestly inadequate for the unique developmental and cultural needs of our young people. If we are to reduce the impact of mental disorder on this most vulnerable population group, transformational change and service redesign is necessary. Here, we present three recent and rapidly evolving service structures from Australia, Ireland and the UK that have each worked within their respective healthcare contexts to reorient existing services to provide youth-specific, evidence-based mental healthcare that is both accessible and acceptable to young people.
BackgroundTransfer of care from one healthcare provider to another is often understood as a suboptimal version of the process of transition.AimsTo separate and evaluate concepts of transfer and transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS).MethodIn a retrospective case-note survey of young people reaching the upper age boundary at six English CAMHS, optimal transition was evaluated using four criteria: continuity of care, parallel care, a transition planning meeting and information transfer.ResultsOf 154 cases, 76 transferred to AMHS. Failure to transfer resulted mainly from non-referral by CAMHS (n = 12) and refusal by service users (n = 12) rather than refusal by AMHS (n = 7). Four cases met all criteria for optimal transition, 13 met none; continuity of care in(n = 63) was met most often.ConclusionsTransfer was common but good transition rare. Reasons for failure to transfer differ from barriers to transition. Transfer should be investigated alongside transition in research and service development.
Summary Although the corrosive effect of mental ill health on human health and happiness has long been recognised, it is only relatively recently that mental illness has been acknowledged as one of the major threats to economic productivity worldwide. This is because the major mental disorders most commonly have their onset during adolescence and early adulthood, and therefore have a disproportionate impact on the most productive decades of life. With the costs associated with mental ill health estimated to double over the next two decades, a greater emphasis on prevention and early intervention has become even more imperative. Although prevention largely remains aspirational for many reasons, early intervention is well within our current reach and offers the potential to significantly reduce the impact of mental ill health on our health, happiness and prosperity in the immediate future.
SummaryBorderline personality disorder (BPD) is a leading candidate for developing empirically based prevention and early intervention programmes because it is common in clinical practice, it is among the most functionally disabling of all mental disorders, it is often associated with help-seeking, and it has been shown to respond to intervention, even in those with established disorder. Moreover, it can be reliably diagnosed in its early stages and it demarcates a group with high levels of current and future morbidity and mortality. Data also suggest considerable flexibility and malleability of BPD traits in youth, making this a key developmental period during which to intervene. Novel indicated prevention and early intervention programmes have shown that BPD in young people responds to intervention. Further work is required to develop appropriate universal and selective preventive interventions.
BackgroundThe limited reach and effectiveness of psychological treatments for adolescent depression have fuelled interest in alternative approaches designed to promote resilience. Schools offer a convenient location for the widespread delivery of depression prevention programmes, although little research has evaluated the feasibility of delivering interventions in this setting.AimsTo investigate the feasibility of delivering and evaluating a universal school-based depression prevention programme for children aged 12-16 years.MethodA three-arm pilot study was conducted in one UK secondary SChOOl (n = 834).ResultsInterventions had good reach (96%), with high rates of consent (89%) and reasonable retention (78%). The majority of intervention sessions were delivered as intended, with 85% of students attending seven or more sessions. The programme was acceptable to students and teachers, with the specific content of the active intervention being rated differently from the control programmes.ConclusionsDelivering and undertaking methodologically robust evaluations of universal school-based depression programmes is feasible.
SummaryIt is now known that the onset of severe and recurring mental health problems begins for the most part before the age of 25: this provides a clear focus for preventive strategies and public mental health that are a feature of many health policy frameworks. The present distinction between child and adolescent mental health services and adult services at 16 or 18 does not fit easily with these data and the now well-documented problems of transition suggest that a fundamental review of services for young people is overdue. This supplement provides an overview of the epidemiological, conceptual and service structures for young people with emergent and existing mental health problems, and asks the question, ‘How should we design services for young people to promote prevention and service engagement, and to improve outcomes?’
This discussion paper outlines our personal views for debate on some of the complexities inherent in the crucial task of improving mental health services for young people in the UK.
