Stigmatisation of people with mental illness, especially schizophrenia, seriously affects their lives by its effects, for example on job prospects and relationships. The Royal College of Psychiatrists’ anti-stigma campaign, Changing Minds: Every Family in the Land, was established to change this. It was a 5-year national campaign that aimed to challenge perceptions of mental health problems and increase knowledge of mental issues. Initially it was agreed that we needed to look at our own attitudes, particularly as there has been serious criticism of these (Reference BregginBreggin, 1991). The Schizophrenia subgroup of the campaign developed a questionnaire to assess attitudes of psychiatrists’ to mental illness, especially schizophrenia.

Method

The questionnaire used items from two survey instruments - the Community Attitudes to Mental Illness (CAMI), developed by Taylor & Dear (Reference Taylor and Dear1981), and one developed at the start of the campaign by the Campaign Management Committee and its Scientific Advisory Committee, carried out by the Office for National Statistics (ONS) for the general public (Reference Crisp, Gelder and RixCrisp et al, 2000). These were supplemented with questions about schizophrenia and its management, developed by the group. Information was requested about respondents’ gender, grade, years since qualification and percentage of case-load with schizophrenia.

The questionnaire was piloted by sending it to psychiatrists in the Southampton area. The response rate was excellent, with 25 of 26 returned, and a range of comments was received that were considered in the redesign of the questionnaire. The questionnaire was estimated to take an average of 8 minutes to complete. The revised questionnaire was then sent to UK members of the Royal College of Psychiatrists, who were asked to return it to a Post Office Box with anonymity assured. The questionnaire was designed using the Teleform computer program for automated data input (produced by Cardiff Software, Inc.), which reads standardised input forms into a database developed for statistical analysis using the Statistical Package for the Social Sciences version 10.

Results

Altogether, 2813 questionnaires were returned (43% of the total). All were included, although some had uncompleted questions: 57.4% were male and 36.8% female (5.8% did not disclose their gender); 65% were consultants, 22% trainees and 7% other grades (6% unknown). Slightly more females than males and more consultants (65%: 55%) responded than other grades, compared with the characteristics of the membership as a whole.

Among the statements from the CAMI (Table 1), it was said that mental hospitals are not viewed as outdated means of treating people. Psychiatrists generally believe that less emphasis should be placed on protecting the public from people with mental illness (59.2%), but some (27.5%) disagree. However, a large majority (95.2%) believes that people with mental illness are far less of a danger than most people suppose, with just 2% disagreeing.

Table 1. Comparison of psychiatrists’ and general population attitudes: community attitudes to mental illness statements

	Agree strongly		Agree		Neither		Disagree		Disagree strongly		Don't know
	Psych	Public	Psych	Public	Psych	Public	Psych	Public	Psych	Public	Public only
One of the main causes of mental illness is a lack of self-discipline and willpower	1	4	1	9	2	15	24	16	72	50	6
There is something about people with mental illness that makes it easy to tell them from normal people	0	4	10	15	9	14	45	20	35	44	3
Less emphasis should be placed on protecting the public from people with mental illness	14	14	45	20	13	26	23	18	4	17	5
Mental hospitals are an outdated means of treating people with mental illness	4	20	18	20	8	19	54	18	15	16	6
Virtually anyone can become mentally ill	50	73	43	19	2	4	4	2	1	1	2
A woman would be foolish to marry a man who has suffered from a mental illness, even though he seems fully recovered	1	3	6	6	22	21	52	22	18	42	6
A man would be foolish to marry a woman who has suffered from a mental illness, even though she seems fully recovered	1	3	6	6	22	17	52	21	18	49	3
I would not want to live next door to someone who has been mentally ill	1	3	4	6	14	17	55	21	25	49	3
No-one has the right to exclude people with mental illness from a neighbourhood	44	53	45	18	4	11	4	7	1	9	2
People with mental illness are far less of a danger than most people suppose	51	34	44	30	3	20	2	8	0	4	4
Most women who were once patients in a mental hospital can be trusted as babysitters	13	8	47	11	25	31	13	20	1	22	8
Residents have nothing to fear from people coming into their neighbourhood to obtain mental health services	33	16	54	28	16	20	12	10	0	4	5

The responses drawn from the ONS survey (Table 2) confirmed that most psychiatrists thought that ‘someone with schizophrenia’ tended not to be dangerous to others, but did tend to be unpredictable and perhaps hard to talk to. However, they were certainly not to blame for their condition or able to pull themselves together. They would improve with treatment, but were ambivalent about whether they would eventually recover and whether they ‘ feel the way we all feel at times’.

Table 2. Comparison of psychiatrists’ and general population attitudes¹

	1		2		3		4		5			Don't know
Think of someone with schizophrenia: which point on each of the scales best describes a person with schizophrenia?	Psych	Public	Psych	Public	Psych	Public	Psych	Public	Psych	Public		Public only
Dangerous to others	1	46	5	25	27	11	52	4	12	5	Not dangerous to others	9
Unpredictable	3	57	36	20	37	7	19	3	1	4	Predictable	9
Hard to talk to	3	31	33	28	39	22	20	6	3	4	Easy to talk to	10
Themselves to blame	1	4	0	3	2	16	16	20	78	47	Not to blame	10
Improve if given treatment	50	23	41	28	5	25	1	9	1	6	Not improve	9
Feel way we all do	25	4	18	7	22	21	21	22	10	36	Feel different	9
Pull themselves together	0	3	2	5	31	17	54	30	11	36	Cannot improve how they feel	9
Recover fully	2	3	24	10	49	27	20	26	2	25	Never recover fully	9

A small majority of the psychiatrists who responded to the question (53.5%) believe that causes of schizophrenia are a balance of both social and biological factors, compared with primarily biological factors (46.1%) (Table 3). Few, however, think that gene therapy will eradicate it. Misdiagnosis of schizophrenia in Black people is considered common (47.9%), with only a quarter considering it uncommon. Although most believe that discussing contents of delusions and hallucinations is appropriate (90.6%) and that family therapy is effective (80.7%), there is still a sizeable group who do not or have no opinion. Many think that antipsychotic medication is prescribed above British National Formulary (BNF) limits too often and that polypharmacy is too common. When telling patients and carers that they have schizophrenia, psychiatrists talked about diagnosis, causation and family relationships, but less about leisure activities, financial matters and accommodation.

Table 3. Questions about psychiatric management

Causes of schizophrenia are	Primarily social (%) 0.4		Primarily biological (%) 46.1	A balance of both biological and social (%) 53.5
Responses	Strongly agree (%)	Agree (%)	Neither (%)	Disagree (%)	Strongly disagree (%)
The psychiatrist has a major role to play in ensuring optimal functioning in the following areas of a patient's life:
a. work	23.3	63.4	5.8	5.9	4.5
b. family relationships	33.8	59.1	2.7	3.1	0.2
c. leisure activity	13.5	55.1	16.8	12.2	0.9
d. financial matters	8.4	41.9	22.4	23.3	2.3
e. accommodation matters	15.8	54.7	9.9	15.0	1.8
Gene therapy will eventually eradicate schizophrenia	0.9	6.1	26.8	47.6	17.4
It is best to avoid discussing the contents of delusions and hallucinations with patients	1.5	4.6	2.6	50.0	40.6
Working with families is an effective treatment for schizophrenia	22.9	57.8	7.4	10.0	1.0
Misdiagnosis of schizophrenia in Black patients is common	5.6	42.3	26.5	23.4	1.7
Patients with schizophrenia are too commonly prescribed doses of antipsychotic drugs above BNF limits	6.3	37.8	21.2	31.8	1.8
Patients with schizophrenia are too commonly prescribed multiple antipsychotic drugs concurrently	10.8	56.6	15.8	15.3	1.0

	Always (%)	Usually (%)	Sometimes (%)	Rarely (%)	Never (%)
When I tell patients that they have schizophrenia, I give them information about:
a. the diagnosis	50.1	37.6	6.4	0.3	4.5
b. causation	28.9	43.3	18.7	3.8	0.6
c. family relationships	19.7	43	27.5	4.3	0.5
d. leisure activities	11.3	31.3	35.9	14.8	1.9
e. financial matters	6.2	19.8	38.0	26.4	4.7
f. accommodation	9.0	30.0	38.6	15.1	2.0
When I tell patients that they have schizophrenia, I give their carers information about:
a. the diagnosis	51.0	37.6	5.9	0.6	0.1
b. causation	32.7	44.0	15.1	2.6	0.3
c. family relationships	29.8	44.5	17.8	2.6	0.2
d. leisure activities	10.7	31.2	37.4	12.9	2.3
e. financial matters	7.7	22.5	37.2	22.6	4.2
f. accommodation	10.2	30.9	36.8	14.0	2.2
I routinely prescribe antiparkinsonian medication when commencing patients on antipsychotic drugs	1.8	6.7	27.8	35.7	23.3
I enjoy working with people with schizophrenia	14.6	61.3	17.2	2.2	0.5

Discussion

The response rate to the questionnaire was 43%, and so the generalisability of the results to all psychiatrists cannot be assumed. However, the findings are worthy of comment and of comparison with general population figures. Inevitably, they reflect psychiatrists’ own perception of their attitudes and may well be distorted in terms of what they perceive to be professionally desirable responses. These attitudes should also reflect their understanding of the evidence base where it exists.

The differences in responses between groups of psychiatrists by grade, case-load and years qualified (but not much by gender) might have relevance to training and clinical governance. More biological beliefs in causation are more common in consultants and those qualified between 10-20 years, but generally the sample slightly favours a balance between social and biological cause, to primarily biological causation. This reflects the continuing debate in the profession.

Misdiagnosis of schizophrenia in Black people is believed to be common, especially by those qualified over 20 years and those not in consultant or trainee posts, but not so much by those with higher caseloads of patients with schizophrenia. This may be surprising in view of research studies, which have suggested such misdiagnosis to be uncommon (Reference Harrison, Owens and HoltonHarrison et al, 1988), but accords with the views of many patient groups and some recent research (Reference Hickling, Mckenzie and MullenHickling et al, 1999). It is possible that such studies using standardised instruments are seen by psychiatrists as not being typical of ‘ normal’ clinical practice where such misdiagnosis may be more common.

Discussion of delusions and hallucinations is deemed no longer to be avoided (except by a group of 10% of those qualifying more than 20 years ago) and is consistent with the increased evidence for psychological treatments of schizophrenia (Reference Sensky, Turkington and KingdonSensky et al, 2000). Consultants and those longer qualified or with higher case-loads of people with schizophrenia give increased information about work, leisure, finances, etc. to patients than others. Family work is generally agreed to be effective in schizophrenia, but there remain a minority who are unconvinced. Prescription of medication above BNF levels, and polypharmacy, is agreed to be too common, especially by trainees and those more recently qualified and still there are substantial numbers of psychiatrists, especially consultants, prescribing antiparkinsonian drugs routinely with new prescriptions of antipsychotics (although this question was asked in such a way as to suggest a dichotomous answer, which may have distorted the results). Each of these findings has implications for basic training and continuing professional development. The findings about antipsychotic and antiparkinsonian prescribing are particularly disappointing and need to be a focus for change, possibly through the development of clinical governance procedures over the next few years.

Mental hospitals are not considered outdated, though less so by consultants and those qualified longer. It is possible that ‘mental hospital’ has been interpreted as meaning acute psychiatric unit, wherever sited, which may explain the very positive view from the majority of respondents compared with the general population.

In terms of attitudes, psychiatrists do seem to generally hold non-stigmatising views in comparison with the general population, although as in any group there are exceptions. The emphasis on protection of people from those with mental illness is believed to be excessive by most, as they are considered ‘far less of a danger than most people suppose’. Most psychiatrists do not agree that a man or woman would be foolish to marry someone with mental illness but the longer qualified, the less likely is an opinion on this to be offered. Similarly, most believe that ‘most women who were once patients in a mental hospital can be trusted as babysitters’. In considering ‘someone with schizophrenia’, most psychiatrists thought that they were not likely to be dangerous to others, but might be hard to talk to and unpredictable. This latter view was less likely where caseload of people with schizophrenia was higher, suggesting that direct personal experience improves understanding. Finally, psychiatrists are more optimistic about recovery than the public.

In summary, the attitudes of psychiatrists towards people with mental illness, especially schizophrenia, are generally positive compared with those of the general population. Individually and collectively, they are wellplaced to take leading roles in combating stigmatisation. Some findings, e.g. that many psychiatrists think that Black people are commonly misdiagnosed, warrant further discussion and investigation. Some aspects of management, especially the use of antipsychotic medication, need to be addressed by individuals themselves, and through training and clinical governance. The samples of psychiatrists and the general population were not matched, for example for age and gender, although these factors did not appear to have a major influence on the results. Responses to questionnaires are based on individuals’ perceptions of their attitudes, and may not be reflected in how they are perceived by others or in their clinical practice.

Finally, and fortunately, an overwhelming majority of psychiatrists working with people with schizophrenia enjoy doing so. This survey highlights areas for improvement in training and personal development plans, and for reducing stigmatisation. Using such surveys in other groups, e.g. general practitioners, nurses, social workers and politicians, might improve the focus and impact of stigma campaigns.

Declaration of interest

None. Funding is described in the acknowledgements.