"Mental health literacy": a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment

OBJECTIVES

To assess the public's recognition of mental disorders and their beliefs about the effectiveness of various treatments ("mental health literacy").

DESIGN

A cross-sectional survey, in 1995, with structured interviews using vignettes of a person with either depression or schizophrenia.

PARTICIPANTS

A representative national sample of 2031 individuals aged 18-74 years; 1010 participants were questioned about the depression vignette and 1021 about the schizophrenia vignette.

RESULTS

Most of the participants recognised the presence of some sort of mental disorder: 72% for the depression vignette (correctly labelled as depression by 39%) and 84% for the schizophrenia vignette (correctly labelled by 27%). When various people were rated as likely to be helpful or harmful for the person described in the vignette for depression, general practitioners (83%) and counsellors (74%) were most often rated as helpful, with psychiatrists (51%) and psychologists (49%) less so. Corresponding data for the schizophrenia vignette were: counsellors (81%), GPs (74%), psychiatrists (71%) and psychologists (62%). Many standard psychiatric treatments (antidepressants, antipsychotics, electroconvulsive therapy, admission to a psychiatric ward) were more often rated as harmful than helpful, and some nonstandard treatments were rated highly (increased physical or social activity, relaxation and stress management, reading about people with similar problems). Vitamins and special diets were more often rated as helpful than were antidepressants and antipsychotics.

CONCLUSION

If mental disorders are to be recognised early in the community and appropriate intervention sought, the level of mental health literacy needs to be raised. Further, public understanding of psychiatric treatments can be considerably improved.

The reliability and validity of the Mini-Mental State in a British community survey

The Mini-Mental State (MMSE) was administered to 2302 general practice patients aged 75 yr and over. Those scoring 23 or less and a sample of those scoring 24 or 25 were selected for further investigation using the Cambridge Mental Disorders of the Elderly Examination. Inter-observer reliability was high with a mean kappa value of 0.97. Eighty-six per cent of respondents judged to have organic mental disorders scored 23 or less on the MMSE and 92% of those judged to be cognitively intact scored 24 or more. However, only 55% of respondents who scored 23 or less were demented or delirious while a number of relatively well educated, mildly demented subjects scored 24 and 25. The customary cut-off point of 23/24 may need to be revised in future community studies. MMSE scores cannot be used to make even tentative psychiatric diagnoses; more detailed investigation of low scorers is essential.

Do general practitioners miss dementia in elderly patients?

General practitioners and community nurses were asked to rate the likelihood of dementia for each of their elderly patients. Cases of dementia were identified by research psychiatrists using the Cambridge mental disorders of the elderly examination (CAMDEX), a new structured diagnostic interview. General practitioners correctly identified dementia as at least a possibility in 121 of the 208 cases found. Nevertheless, they mistakenly rated as demented several patients suffering from functional psychiatric disorders, in particular depression. Community nurses correctly identified dementia as at least a possibility in 64 of the 74 demented patients known to them, but they incorrectly suspected dementia in a greater proportion of instances. Both general practitioners and families appeared to have low expectations of what general practice has to offer demented elderly people. General practitioners should take the initiative in diagnosing dementia in very elderly patients who show signs of the condition. In some cases it may be secondary to treatable disorders, and in others all that may be required are understanding, support, and advice to families.

Helpfulness of interventions for mental disorders: beliefs of health professionals compared with the general public

BACKGROUND

The study aimed to compare the beliefs of health professionals about the potential helpfulness of various mental health interventions with those of the general public.

METHOD

Surveys were carried out in Australia of 872 general practitioners, 1128 psychiatrists, 454 clinical psychologists and 2031 members of the public. Respondents were presented with a case vignette describing either a person with depression or one with schizophrenia. Respondents were asked to rate the likely helpfulness of various types of professional and non-professional help and of pharmacological and non-pharmacological interventions.

RESULTS

The professionals gave much high ratings than the public to the helpfulness of antidepressants for depression, and of antipsychotics and admission to a psychiatric ward for schizophrenia. Conversely, the public tended to give much more favourable ratings to vitamins and minerals and special diets for both depression and schizophrenia, and to reading self-help books for schizophrenia.

CONCLUSION

The beliefs that health practitioners hold about mental disorders differ greatly from those of the general public. There is a need for mental health education campaigns to help close the gap between professional and public beliefs.

The influence of education, social class and sex on Mini-Mental State scores

The Mini-Mental State Examination was administered to 1865 general-practice patients aged 75 years and over. Even when demented cases were removed from analysis, respondents with relatively little education, together with those in social classes III-manual and below, were significantly more likely to score below the cut-off point used in North American community surveys to denote 'cognitive impairment'. Education and social class influenced scores on all sections within the MMSE with the exception of registration. Sex influenced scores on tests of calculation and spelling backwards but had no effect on total scores. These findings emphasize the importance of investigating low scorers in more detail before making a diagnosis of dementia.

Memory complaints and impairment in normal, depressed, and demented elderly persons identified in a community survey

Normal, depressed, and demented elderly persons who were identified by means of a community survey were asked to assess their memories and to complete a battery of memory tests. Depressed elderly persons reported memory problems more often than normal subjects and reported indecisiveness, impaired concentration, and mental slowing more often than demented subjects. However, memory complaints and memory performance correlated poorly in the normal and depressed groups. Normal and demented elderly persons who reported memory problems achieved higher scores on a series of questions about depression than those who denied memory problems.

Incidence of dementia in a population older than 75 years in the United Kingdom

BACKGROUND

Incidence studies have been relatively neglected in psychiatric epidemiology. They are particularly important for dementia, since prevalence rates are affected by length of survival, which itself falls with increasing age and presence of dementia.

METHODS

Two-wave community study of 1195 elderly subjects aged older than 75 years, restudied 2.4 years after a community prevalence study. A two-stage method was used, comprising the Mini-Mental State Examination followed in a stratified sample by the Cambridge Examination for Mental Disorders of the Elderly (CAM-DEX) interview. Incidence rates were based on person-years at risk.

RESULTS

Annual incidence rates for dementia were 2.3% for subjects initially aged 75 to 79 years, 4.6% for ages 80 to 84 years, and 8.5% for ages 85 to 89 years, approximately doubling every 5 years. Rates did not differ significantly by sex, educational level, or social class. Twice as many additional individuals received a diagnosis of minimal dementia not reaching case threshold.

CONCLUSIONS

The findings show high rates of new onset dementia, increasing markedly with age, and suggest rapid acceleration of one or more processes that is common in advanced age.

The prevalence of dementia as measured by the Cambridge Mental Disorders of the Elderly Examination

General practice patients aged 75 years and over were screened for cognitive impairment using the Mini-Mental State Examination. Those scoring 23 or below and a sample of those scoring 24 or 25 were assessed using the Cambridge Mental Disorders of the Elderly Examination (CAMDEX), a structured interview schedule specifically designed to detect mild dementia. The CAMDEX includes a mental state examination, a psychiatric history, detailed cognitive testing and an information interview. The prevalence of dementia in 2311 patients was found to be 10.5%, about half that found in most earlier studies. Possible reasons for this low rate are discussed.

Problems reported by relatives in a community study of dementia

The supporters of 120 demented elderly people completed rating scales of the frequency and severity of the problems they faced, the amount of strain they experienced and their psychological well-being. Problems and strain increased with the degree of dementia. Problems relating to physical dependency, forgetfulness and inertia were relatively common, while disturbed behaviours were relatively uncommon. Physical dependency and disturbed behaviour were less well tolerated than forgetfulness and inertia, but all problem categories were positively associated with measures of strain. Wives reported more problems and strain than husbands, and co-resident children were under greater strain than children who lived independently.

Public beliefs about causes and risk factors for depression and schizophrenia

The objective of this study was to carry out a national survey to assess the Australian public's beliefs about causes and risk factors for mental disorders. A national household survey of 2,031 Australian adults was carried out. Half the respondents were presented with a vignette describing a person with major depression and the other half with a vignette describing schizophrenia. Respondents were asked to rate whether various factors are likely causes of problems such as that described in the vignette and to rate whether various groups are at higher or lower risk. For depression, social environmental factors were often seen as likely causes, which is consistent with the epidemiological evidence. However, genetic factors were considered as a likely cause by only half the population. For schizophrenia, social environmental factors were also often seen as causes, which is in contrast to the weak epidemiological evidence for such a role. Genetic factors attracted more support as a cause of schizophrenia than of depression. These findings point to areas where the mental health literacy of the population could be improved, particularly the over-emphasis on social environmental factors in schizophrenia. Of some concern was the belief of half the population that weakness of character is a likely cause of both depression and schizophrenia. This belief implies a negative evaluation of the sufferer as a person.

Beliefs about the helpfulness of interventions for mental disorders: a comparison of general practitioners, psychiatrists and clinical psychologists

OBJECTIVE

The aim of this study was to assess health professionals' beliefs about the helpfulness of a broad range of possible interventions for mental disorders.

METHOD

The study involved a postal survey of 872 general practitioners (GPs), 1128 psychiatrists and 454 clinical psychologists. These health practitioners were presented with a vignette describing either a person with schizophrenia or one with depression. The vignettes were taken from an earlier survey of the general public. Respondents were asked to rate the likely helpfulness of various types of professional and non-professional help and of pharmacological and non-pharmacological interventions.

RESULTS

Two-thirds or more of each profession agreed that the person with schizophrenia would be helped by GPs, psychiatrists, clinical psychologists, antipsychotic agents and admission to a psychiatric ward. Similarly, two-thirds agreed that the person with depression would be helped by GPs, psychiatrists, clinical psychologists, antidepressants, counselling and cognitive-behavioural therapy. However, there were also areas of disagreement. Psychiatrists were less likely than GPs and clinical psychologists to rate psychological and lifestyle interventions as helpful, while clinical psychologists were less likely to rate specifically medical interventions as helpful. Younger members of the professional groups and female members (who also tended to be younger) tended to rate a wider range of interventions for each disorder as likely to be helpful.

CONCLUSIONS

Despite areas of broad agreement about treatment, health practitioners were more likely to endorse the interventions associated with their own profession. However, younger members of each profession tended take a broader view. If these age differences represent a cohort effect, health professionals may in the future show greater acceptance of the helpfulness of interventions offered outside their profession. These conclusions are limited by the methodology of the survey, which involved a questionnaire designed for the public rather than professionals.

The influence of education and social class on the diagnosis of dementia in a community population

We have reported previously that poorly educated elderly people and those of low social class were at much increased risk of scoring below the customary cut-point on the Mini-Mental State Examination, a widely-used, brief cognitive screening test. As part of the same study, subjects who scored 23 or less on the MMSE out of a maximum of 30 points, and a sample of those who scored 24 or 25 points, were assessed by psychiatrists using a structured, diagnostic interview. Assuming that persons who scored 26 points or above were cognitively intact (our data suggest that 2% or less were not), neither educational attainment nor social class had any influence on the likelihood that subjects would be diagnosed as demented. Our data suggest that social and psychological factors contribute substantially to cognitive test scores and serve to emphasize the importance of detailed assessment procedures in epidemiological surveys of dementia.

Does early intervention reduce the number of elderly people with dementia admitted to institutions for long term care?

OBJECTIVE

To test whether early diagnosis and practical help reduce the number of elderly people with dementia admitted to institutions.

DESIGN

Controlled trial of effect of help from a multidisciplinary team on admission rates of people with dementia.

SETTING

Seven general practices in Cambridge.

SUBJECTS

2889 subjects aged 75 and over, of whom 159 were identified as having dementia with a two stage community survey. Eighty six subjects were referred for extra help if they or their supporters wished. The other 73 subjects had access to the usual services and served as controls.

INTERVENTION

Subjects and families in the action group were offered a wide range of help, including financial benefits, physical aids, home helps, respite admissions, practical advice, and psychiatric assessments.

MAIN OUTCOME MEASURE

Permanent admission to long term care within two years after diagnosis.

RESULTS

Early intervention did not affect admission rates in subjects who lived with supporters. By contrast, nine of the 14 (64%) subjects with moderate or severe dementia living alone were admitted in the action group in the study's second year compared with only one of 13 (8%) controls (p = 0.004).

CONCLUSIONS

Some people with moderate or severe dementia who lived alone and were at serious risk may have been identified earlier by the resource team. Without the team these people would not have become known to the responsible authorities until families, neighbours, and wardens became unable to cope. The study was conducted during the team's formative period, however, and greater experience might have allowed some subjects to remain at home for longer.

Belief systems of the general public concerning the appropriate treatments for mental disorders

A study was conducted to assess the belief systems of the general public concerning the appropriate treatments for mental disorders and correlates of these belief systems. The study was based on the results of a household survey of the general public in Australia, using a national random sample of 2,031 adults aged 18-74 years. Respondents were given a vignette describing either a person with depression or one with schizophrenia, and were asked for their opinions about the helpfulness of various professional and non-professional treatments for the person described. A principal components analysis of the helpfulness ratings gave three factors: a Medical factor with high loadings on all drug treatments (except Vitamins) and on Psychiatric ward and ECT; a Psychological factor with high loadings on Counsellor, Social Worker, Phone counselling, Psychiatrist, Psychologist, Psychotherapy and Hypnosis; and a Lifestyle factor with high loadings on Close family, Close friends, Naturopath, Vitamins, Physical activity and Get out more. The same factors emerged from ratings of the two vignettes. Mean scores on scales constructed from the items with high loadings showed that the public tend to have a negative view of medical treatments and a positive view of psychological and lifestyle ones. However, medical treatments were rated more negatively for depression than for schizophrenia, psychological treatments were rated more positively for schizophrenia, and lifestyle treatments more positively for depression. Age, sex and education of respondents showed few associations with scores on the scales, although the better educated were more in favour of psychological treatments for both depression and schizophrenia and were less opposed to medical treatments for schizophrenia. Respondents who had suffered from the symptoms described in the schizophrenia vignette were more negative towards medical treatments. These findings about public belief systems could have implications for the provision of treatment: where there is a discrepancy in belief system between the patient and the clinician there may be poor adherence to treatment.

Dementia in old age: an anthropological perspective

This paper examines the assumption that dementia in old age is a universal phenomenon that will vary in its prevalence and manifestation because of social and cultural factors. It finds that while researchers have been successful in demonstrating the commonality of dementia, they have been less successful in showing whether or not it varies across cultures and between social and ethnic groupings. The inconclusiveness of findings may, in part, be a function of diagnostic differences and the research methodologies employed. New instruments and measures are being devised to overcome these problems. However, the sociocultural context in which dementia occurs and the meaning of the disorder to those involved (as sufferers and caregivers) are often missing dimensions. In particular, there is little knowledge about how the disorders of old age in non-Western settings are experienced and understood. In this respect anthropology has a special contribution to make to research on dementia.

Continued clinical validation of dementia diagnosed in the community using the Cambridge Mental Disorders of the Elderly Examination

We describe the outcome 2 years later of elderly Cambridge residents who had been diagnosed as demented using the Cambridge Mental Disorders of the Elderly Examination. Mortality rates were high but diagnoses were confirmed for all of the 43 moderate and severe cases who survived for this period, and for 51 of the 56 subjects who had been rated initially as mildly demented; 28 of the 56 mildly demented subjects progressed to more severe levels of impairment. As many as 12 of the 24 original minimally demented cases showed evidence of intellectual deterioration, which lends weight to the validity of this experimental category.

The problem of dementia in Australian aboriginal and Torres Strait Islander communities: an overview

The concept of dementia in old age in Australian Aboriginal and Torres Strait Islander communities is intrinsically paradoxical. Firstly, few indigenous people reach old age. Secondly, from some indigenous points of view, dementia is either not recognized as a condition or as a problem, or, in the case of the more disruptive manifestations of cognitive impairment, is perceived as 'madness'. Moreover, in the wider context of profound political, social and economic inequality experienced by most indigenous people, the western medical category of dementia may appear to be of relatively minor importance. However, government initiatives in aged care generally and dementia care in particular which are designed to address the ageing of the Australian population as a whole also include the nation's older indigenous people. This article-based on a review of published work, supplemented by discussions with indigenous and non-indigenous individuals involved in indigenous aged care and mental health-examines some of the issues surrounding cognitive decline in old age for Aborigines and Torres Strait Islanders. More specifically, it looks at the problems involved in assessing and diagnosing cognitive decline and dementia, especially among people who follow more traditional ways of life, and in providing services to sufferers and their carers. In doing so, it considers some of the relative meanings of "old age', "abnormal old age', "mental disorder', "sickness' and "dementia'.

Coexisting depression and dementia in a community survey of the elderly

We report here on the coexistence of dementia and depression in a community population aged 75 years and older. Complete information about mood and cognition was available for 286 cognitively intact subjects selected for assessment because of their low scores on the Mini-Mental State, and for 158 mildly and moderately demented subjects. Severely demented subjects, who were incapable of providing information, were excluded. Five percent (8/158) of demented subjects also fulfilled criteria for major depressive disorder Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) compared with 9% (27/286) of cognitively intact subjects. No substantial differences existed in the symptoms reported by demented depressives and nondemented depressives, but subjects who suffered from both disorders were so markedly apathetic that their depression might easily have been overlooked had specific enquiries not been made. Depression was particularly associated with dementia secondary to multi-infarct and Parkinson's disease. When reviewed one year later, 2 of the 18 surviving depressed, nondemented subjects showed evidence of dementia. Both presented unusual diagnostic difficulties, however, and no evidence emerged that large numbers of elderly people will be misclassified in community surveys that include a mental state examination, cognitive testing, and an informant interview.

A follow-up study of dementia diagnosed in the community using the Cambridge Mental Disorders of the Elderly Examination

Elderly Cambridge residents diagnosed as demented using the Cambridge Mental Disorders of the Elderly Examination (CAMDEX) were reviewed approximately 12 months later. Diagnoses were confirmed in 133 of 137 surviving cases (97%). Subjects said to have minimal dementia (cognitive impairment insufficient to warrant a diagnosis of dementia proper) had a varied outcome. Only 6 out of 29 survivors showed progressive intellectual deterioration and 13 were reclassified as normal. Subjects passed as normal in the first year of the study were reviewed using the Mini-Mental State Examination. We cannot be certain how many were actually dementing, but our findings suggest that only a small number of false negative diagnoses were made in the first year of the study.

The progression of mild idiopathic dementia in a community population

Thirty-one subjects aged 75 years and over who were identified as suffering from mild, idiopathic dementia in a large community survey were reviewed at annual intervals for 2 years. Diagnoses and severity ratings were based on defined criteria following a mental state examination, a medical and psychiatric history, detailed cognitive testing, and an interview with relatives or other key informants. Fourteen subjects became more severely demented within 2 years. The initial cognitive test battery failed to reveal any differences between respondents whose dementia advanced and those whose condition remained unchanged, but, in the former group, subjects' symptoms had been present for longer, and a greater proportion had been recognised as demented, or possibly demented, by their general practitioners. We suggest that subjects whose dementia progressed had actually been more severely disabled at the time of identification.

Cognitive impairment: a challenge for community care. A comparison of the domiciliary service receipt of cognitively impaired and equally dependent physically impaired elderly women

OBJECTIVES

to compare the domiciliary service receipt of cognitively impaired and equally dependent physically impaired elderly women prior to the passing of the UK Community Care Act.

METHODS

secondary analysis of a population survey conducted in 1986 in the city of Cambridge. The analysis used data on 1585 women aged 75 and over living in the community. The effect of type of impairment on the receipt of domiciliary services (meals-on-wheels, home help and community nursing) is measured using a multivariate model which allows for adjustment for dependency level and other potential confounding factors.

RESULTS

the odds of an elderly woman getting help from any of the domiciliary services whilst not being significantly affected by cognitive impairment (odds ratio 0.7, 95% CI 0.5-1.2) are increased by physical impairment (odds ratio 1.8, 95% CI 1.2-2.5). Similar results were found for the home help service. The differences were exaggerated in the case of the community nursing service, whilst receipt of meals-on-wheels was similar for women of with all types of impairment.

CONCLUSIONS

in the late 1980s, cognitively impaired elderly women received less help from the domiciliary services than equally dependent physically frail women who lived in similar household circumstances. The development of specialist services appropriate to the needs of cognitively impaired elderly people presents a challenge to community care policy, especially since this group are at high risk of institutionalization.

Predictors of hospital contact by very elderly people: a pilot study from a cohort of people aged 75 years and over

We wished to test the hypothesis that elderly people with impaired cognitive function were heavier users of both outpatient and inpatient hospital services. In a retrospective cohort study, 144 elderly people aged 75-97 years (50 men and 94 women) identified from a prevalence survey of dementia were traced over an average period of 4 years. They were categorized into three groups: cognitively impaired, physically frail and physically healthy. Elderly people with impaired cognitive function had fewer contacts with outpatient services (p = 0.0003) but did not differ in inpatient service use from subjects with normal cognitive function. Cognitively impaired people who lived alone had longer hospital stays (p = 0.002) and a higher admission rate to geriatric wards (p = 0,009). Negative self-rated health was an important factor predicting more contacts for men with inpatient services and geriatric outpatient services (both p = 0.002). Use of surgical outpatient services was associated with use of surgical inpatient services by the physically healthy group only (p = 0.0003). After adjusting for age, sex and physical health, cognitively impaired subjects were nearly twice as likely to die within four years as the other two groups (RR = 1.89).

Clinical issues relating to the diagnosis of mild dementia in a British community survey

Many epidemiologists base their diagnoses of dementia on scores on brief cognitive tests, but the border between normal aging and mild dementia is so poorly understood that simple demarcations cannot adequately encapsulate the wealth of clinical material that needs to be taken into account in assigning diagnostic labels. Data from a British study of the prevalence and natural history of dementia, in which diagnoses of dementia were made by clinicians using a new, standardized interview schedule, are presented to demonstrate the effects of physical disability, psychiatric illness, and other factors on memory impairment and performance in everyday life. Our purpose is not to insist that clinicians are always correct but rather to highlight the complexities involved and the need for investigators to be more open about the way in which they distinguish between physical, psychiatric, and cognitive infirmities.

A community survey of mental and physical infirmity in nonagenarians

One hundred and thirty-two people aged 90 years and over were identified in a study of the prevalence of dementia. One third lived in institutions, a third were demented and half were unable to prepare a simple meal or do light housework. None was entirely free of mental or physical disability but many functioned satisfactorily at a simple level with the help of family members and the domiciliary services.