Public confusion caused by differing understandings of the term ‘mental illness’

A health professional’s understanding of the term ‘mental illness’ is likely to be based on that outlined in DSM-IV, but when a member of the public hears the term, what do they understand?

Rusch et al. (2012) have addressed this issue by examining the links between classification of various disorders as mental illness and attitudes towards, and contact with, people with mental illness, intentions to disclose a mental illness and to seek treatment. They used data from an Omnibus Survey carried out in the UK in 2009 and 2010. They concluded that referring to major psychiatric disorders as mental illnesses may reflect higher mental health literacy, better attitudes towards people with mental illness and help-seeking, whereas using the terms ‘behavioural’ or ‘stress-related conditions’ to refer to mental illnesses (a broader concept of mental illness) could increase negative attitudes.

In order to explore what the Australian public understands by the term ‘mental illness’, we have looked at data from the 2011 National Survey of Mental Health Literacy and Stigma, for which telephone interviews were carried out with 6019 Australians aged 15 or over. Participants were presented with a case vignette describing either depression, depression with suicidal thoughts, early schizophrenia, chronic schizophrenia, social phobia or Post-traumatic stress disorder (PTSD) (see Reavley and Jorm (2011) for further details). Among other questions, respondents were asked what, if anything, they thought was wrong with the person described in the vignette. Table 1 shows the most common answers to this question.

Table 1.

Percentage (and 95% CI) of respondents mentioning each category to describe the problem shown in the vignette

	Disorder depicted in the vignette
Category mentioned	Depression	Depression with suicidal thoughts	Early schizophrenia	Chronic schizophrenia	Social phobia	PTSD
Mental illness	2.8 (1.8–4.4)	4.0 (2.8–5.7)	19.2 (16.7–22)	35.4 (32–38.9)	3.7 (2.6–5.1)	3.4 (2.2–5.0)
Depression	73.7 (70.4–76.7)	86.0 (83.1–88.4)	38.1 (34.8–41.5)	5.6 (4.1–7.5)	20.1 (17.4–23.1)	19.8 (17.2–22.7)
Schizophrenia	0 (0–0.6)	0.5 (0.2–1.3)	37.3 (34.0–40.7)	31.9 (28.7–35.2)	1.1 (0.5–2.1)	0.9 (0.4–1.9)
Psychological/mental/emotional problems	1.6 (1.0–2.8)	2.6 (1.6–4.1)	8.4 (6.7–10.4)	10.6 (8.6–13.1)	4.1 (3.0–5.6)	5.5 (4.0–7.5)
Anxiety/anxious	11.1 (7.3–16.4)	11.8 (7.0–19.2)	9.6 (6.1–14.8)	1.9 (0.8–4.7)	32.7 (29.0–36.7)	14.8 (12.1–18.1)
Anxiety disorder	0 (0–0.6)	0.4 (0.1–3.0)	0 (0–0.6)	0 (0–0.6)	2.4 (1.5–3.8)	0.1 (0–0.5)
Social phobia	0 (0–0.6)	2.1 (0.6–11.2)	2.4 (0.8–6.9)	0 (0–0.6)	9.2 (6.9–12.1)	0.8 (0.3–2.1)
Shy	0 (0–0.6)	0 (0–0.6)	0 (0–0.6)	0 (0–0.6)	20.0 (17.0–23.4)	0 (0–0.6)
Low self–confidence/self–esteem	3.9 (1.7–8.5)	12.9 (8.1–20.0)	3.1 (1.5–6.2)	2.4 (0.9–6.0)	18.3 (15.4–21.6)	0 (0–0.6)
PTSD	0.3 (0–2.1)	0 (0–0.6)	0.9 (0.2–3.7)	0.8 (0.2–2.8)	0.2 (0.1–0.9)	37.5 (33.5–41.6)
Fear/scared	0 (0–0.6)	0 (0–0.6)	1.8 (0.5–5.6)	1.1 (0.3–3.4)	3.9 (2.4–6.1)	12.2 (9.4–15.6)
Trauma	0 (0–0.6)	0 (0–0.6)	0 (0–0.6)	0.7 (0.2–2.7)	0.1 (0–0.4)	13.3 (10.5–16.6)
Stress	7.1 (5.4–9.3)	2.8 (1.8–4.5)	1.3 (0.7–2.4)	0.1 (0–0.5)	0.9 (0.5–1.8)	15.0 (12.7–17.6)

PTSD, Post-traumatic stress disorder

As can be seen, the likelihood of the term ‘mental illness’ being used to describe the person in the vignette was notably higher for the early schizophrenia (19.2%) and particularly, the chronic schizophrenia (35.4%) vignettes. This suggests that the public associates the term ‘mental illness’ with schizophrenia rather than the more prevalent affective and anxiety disorders. This interpretation of the term contrasts with the broader one of professionals and may contribute to a credibility issue when discussing mental illness with the public. This is exemplified by the debates about unmet need for services and the possible inclusion of new disorders in DSM-5.

The issue of funding for services and research for mental health in Australia has received relatively prominent media coverage in the last couple of years. While there is general agreement that more funding is needed, health professionals and consumer advocates often differ in their views on how that money should be spent (Allen and Jackson, 2011; Hickie et al., 2011; Jorm, 2011; Pirkis et al., 2011).

Those advocating for more funding often cite statistics on the prevalence of mental illness in the community as well as the levels of unmet need, for example, a commonly-cited statistic in these recent debates is that one in five adults, or one in four young people, suffers from mental illness. Extrapolating from these figures has led to recent claims by Professor Patrick McGorry that ‘700 000 young people are locked out of access to care’ (Burton-Bradley, 2010). There is debate in professional circles about these figures, with others in the field claiming that these figures include those with mild and transient disorders who may not need treatment (Short, 2011; Sweet, 2010; Medew, 2010). As with physical illnesses such as the common cold, symptoms do not necessarily imply the need for treatment.

This is perhaps best exemplified by an analysis of findings from the 2007 National Survey of Mental Health and Wellbeing (NSMHWB), which show that the gulf between prevalence and help seeking in young people is largely due to high rates of harmful use of alcohol in young men (Reavley et al., 2010). While binge drinking is a significant issue, it is likely that many members of the public would be surprised by its categorisation as a mental illness, particularly at the milder end.

With the imminent release of DSM-5 there have been fierce debates about the possible inclusion of a number of new conditions (McGorry, 2011; Rosenman and Anderson, 2011). A number of health professionals and professional bodies have warned against the medicalisation of natural and normal responses to experiences (British Psychological Society, 2011; Kelland, 2012), citing risks such as the labelling of increasingly large numbers of people as mentally ill, as well as the potential for unnecessary treatment. Such controversies are also likely to contribute to public confusion about mental illness.

Debates among professionals about the meaning of prevalence figures and the extent of unmet need are a healthy thing. However, when the debate crosses into the public domain, we would argue that those advocating for increased funding for services and research should clearly define what they mean by the terms ‘mental illness’ and ‘unmet need’ or else refer to specific disorders. Few would argue that the level of unmet need for treatment for those with severe disorders remains an issue of considerable significance without the need for using figures that risk a credibility gap in the eyes of the public (Burgess et al., 2009).

Implications for awareness and stigma reduction campaigns

The issue of public understanding of the term ‘mental illness’ also has implications for stigma reduction campaigns. Given that the public largely associates the term ‘mental illness’ with more severe disorders, it is likely that ‘mental illness’ is acceptable for anti-stigma campaigns that focus on these disorders, while campaigns that aim to de-stigmatise high prevalence disorders should use specific labels, as beyondblue has done in its campaigns that focus on depression and, more recently, anxiety.

We also highlight the risks of broadening public conception of the label ‘mental illness’ to include lower prevalence disorders, as this may risk spreading the stigmatising attitudes linked to severe illnesses to disorders such as anxiety or depression. There is some evidence from studies of stigmatising attitudes that this may be occurring, with data from longitudinal surveys suggesting that perceptions of dangerousness of those with mental illnesses, including depression are increasing over time (Reavley and Jorm, 2012; Silton et al., 2011; Link et al., 1999).