Attitudes to Mental Illness in the U.K. Military: A Comparison With the General Population [Military Medicine]
By Fear, Nicola T | |
Proquest LLC |
ABSTRACT Objectives: To compare attitudes to mental illness in the
INTRODUCTION
It is well known that deployment and combat exposure can increase the risk of mental health problems and alcohol misuse for military personnel.1-4 If left untreated, such prob- lems impair wellbeing, and impact on family functioning and operational effectiveness of the fighting force.5-7 There- fore, facilitating access to appropriate help and effective treatment is vital.
Several studies have found that the stigma of admitting to a mental illness is the most commonly cited barrier to seeking treatment among military personnel4,8-9 and such beliefs can delay or inhibit treatment.10-13 Negative atti- tudes toward mental illness are known to be a problem in the general population14 and it is hypothesized that such attitudes may be intensified in military culture where traits such as stoicism, psychological resilience, and reserve are promoted and highly valued.9,15 Thus, researchers and policy makers within the military require a clearer understanding of attitudes toward mental illness to develop effective antistigma programmes.4
Using data from two cross-sectional samples of the gen- eral population and the military, the study aims are first to compare attitudes to mental illness in the
METHODS
Study Populations andData Collection
This study is based on two large population based cross- sectional surveys, which collected data on mental health atti- tudes. One survey with a sample size of 1,729 residents from
GeneralPopulation Data
In 2007, a survey was commissioned by the
Military Data
A sample of military personnel was drawn from Phase 1 of the King's
The participants for the current study were drawn from those who completed questionnaires from Phase 1 of the KCMHR military health study and consented to follow-up. A "two-phase survey" technique was used, as one of the original objectives of the survey was to identify the preva- lence of psychiatric diagnoses in the whole KCMHR military health study sample.2 Possible psychiatric cases were identi- fied from Phase 1 data and were oversampled as the outcomes of interest (service use and help-seeking) were only relevant to cases. To ensure adequate power to make statistical infer- ences, the sample was stratified by regular/reserve status (50% each) and deployment status (50% deployed on TELIC 1, 50% deployed elsewhere or were not deployed). In all other respects, group participants were representative of the KCMHR military health study responders with regards to Service branch and demographic characteristics (age, rank, ethnicity) and in turn the main study was representative of the
Attitudes to Mental Health
Participants in both surveys were presented with a series of statements about mental illness. The general population was presented with 27 statements, whereas the military sample was presented with five statements. The five state- ments and response options presented to the military popu- lation were identical to five of those presented to the general population and are described here. Three of these state- ments addressed the themes (outlined by the
Statistical Analysis
For analysis, the response option "strongly agree" was com- bined with "agree," and the response option "strongly dis- agree" was combined with "disagree." For each statement, the proportion of those answering "agree," "disagree," "don't know," and "neither agree nor disagree" was calcu- lated, with the standard error. This was done for both the military and the general population sample separately. The samples were stratified by age and sex and the proportions choosing each response option were also calculated for these subgroups. Differences in the point estimates of the two populations were deemed to be statistically signifi- cantly different if the two 95% confidence intervals did not overlap. All proportions were weighted to take account of the sampling strategies used in the two samples using the survey command in STATA. Weighting for the military sample was based on the inverse of the sampling weight for the three characteristics that were oversampled in the study (reserve status, deployment status, and psychiatric caseness). General population survey data were weighted to match the population profile by region. All statistical analyses were undertaken using the statistical software package STATA (version 10 for Windows).
Ethics
The military study received approval from both the
RESULTS
Table I shows that males and those aged 35 to 54 years made up the majority of the military sample, whereas the general population sample was evenly distributed by age and gender.
Mental Illness Is an Illness Like AnyOther
The majority of respondents in the military (68.4%) and the general population (72.9%) agreed with this statement (Table II and Fig. 1). However, disagreement with this statement was higher in the military (26.1%) than in the general population (17.1%). When the results were strati- fied by sex, the proportion of men in the military dis- agreeing with this statement was significantly higher (27.1%) compared with the proportion of men in the gen- eral population (17.5%). Analysis by age shows the pro- portion disagreeing with the statement declines among older age groups in both samples. Military participants aged 16 to 34 years were more likely to disagree with this state- ment than the general population (military 33.0% vs. popu- lation 23.0%); and military participants were less likely to "Neither agree nor disagree," than 16 to 34 year olds in the general population (military 4.4% vs. population 13.1%).
One of the Main Causes of Mental Illness Isa Lack of Self-Discipline and Willpower
In total, 81.3% of military personnel disagreed with this statement, compared to 62.4% of the general population (Table II and Fig. 2). Stratification by age and sex showed there was significantly higher disagreement with this state- ment in the military in both sexes and in 16 to 34 and 35 to 54 year olds compared to the general population. Within the military, 0.3% answered "Don't Know" and 6.8% answered "Neither agree nor disagree" in response to this statement, and the proportion answering in this way was significantly higher in the general population (6.7% vs. 16.6%, respectively).
People With Mental Illness Should NotBe Given Any Responsibility
The majority of participants in both the military (62.6%) and the general population (63.8%) disagreed, and the proportion agreeing with this statement was low in both samples (military 11.9% vs. population 14.5%) (Table II and Fig. 3). Approximately, 20% of participants chose "Neither agree nor disagree" in both samples. No differ- ences were found by age and gender.
People With Mental Illness Should Have the Same Rights to aJob As Everyone Else
The proportion agreeing with this statement was lower in the military sample (56.7%) than in the general population (68.0%) (Table II and Fig. 4). Stratification by sex showed that males in the general population agreed more with the statement (68.0%) than males in the military (54.9%). There was no evidence for a difference between females in both samples. The lower level of agreement in the military was seen across all age groups.
Most Women Who Were OncePatients in a Mental Hospital Can Be Trusted As Babysitters
There was no evidence for any difference between the samples in the proportions agreeing or disagreeing with this statement (Table II and Fig. 5). A larger proportion of the military answered "Don't Know" (military 15.3% vs. popula- tion 6.5%) whereas a larger proportion of the general popu- lation answered "Neither agree nor disagree" (population 33.6% vs. military age and gender.
27.3%). No differences were found by
DISCUSSION
Main Findings
Contrary to popular stereotypes,9,15 the study showed that attitudes toward mental illness are not substantially dif- ferent among military personnel compared to the general population; the majority of respondents from both popu- lations showed positive attitudes toward mental illness, with similar proportions from both populations reporting negative attitudes. Females and older people showed more positive attitudes in both populations. One area of dif- ference between the two populations, however, was that the military showed more positive attitudes about the pri- mary causes of mental illness, specifically in relation to the idea that the main cause of mental illness is a lack of self-discipline and willpower. Another area of difference was that military personnel showed more negative attitudes about integrating people with mental illness into the com- munity and workplace in comparison to the general popula- tion. As our findings indicate, a greater proportion of the military disagreed with the idea that "Mental illness is an illness like any other," as well as the notion that "People with mental illness should have the same job rights as everyone else."
Interpretation of These Results
This is the first study to compare attitudes toward mental illness in the military and general population. Because of the paucity of literature on this subject, we could only speculate if, and how, attitudes toward mental illness differ between these two populations. The masculine culture of the military, which emphasizes the importance of characteristics such as strength and resilience, has led to the hypothesis that the military may hold more negative attitudes to mental illness compared to other groups.9,15 Our findings do not, however, support this hypothesis; below we explore potential explanations for this.
It is likely that the military has greater exposure to mental health education than the general population. Mili- tary personnel are exposed to a range of psychoeducational programmes around deployment, including preoperational, operational, and postoperational mental health briefings,18 which grant them greater awareness about mental illness. In contrast, research has shown that the general population know little about mental illness, not helped by its predomi- nantly negative portrayal in the media.14 Mental health programmes within the military may therefore have had some impact on attitudes, making attitudes toward mental illness more similar, if not more positive, than those of the general population. Furthermore, the military's mental health education programmes highlight the role of external stressors (such as exposure to combat and trauma) in acute breakdown and, in more extreme cases, post-traumatic stress disorder (PTSD), rather than factors such as per- sonality, vulnerability, and childhood may be that such programmes shape the wider military culture's view of the causes of mental illness, explaining the greater disagreement with the belief that the main cause of mental illness is a lack of self-discipline and willpower among the military, compared to the general population.
Alternatively, mental health programmes may have increased awareness of socially desirable attitudes toward mental illness within the military, without causing any fun- damental changes to privately-held attitudes. Social desir- ability bias has been identified as a concern in studies assessing attitudes20 and this effect may have been present in the military study as it was delivered by an organization with funding from the
It is possible that military personnel and the general public interpreted "mental illness" differently, which could have affected their responses. The general public may think of psychotic disorders, such as schizophrenia, which in popular culture are associated with ideas of unpredict- ability, threat, and violence. However, the military is less likely to come into contact with people with such disorders, as they will have been screened out during recruitment and these conditions are not discussed in psychoeducational briefings. Instead, military personnel are more likely to be familiar with mental illnesses such as depression and PTSD, as these are the focus of military mental-health briefings and peer-led schemes such as Trauma Risk Management.21 For example, Trauma Risk Management military practi- tioners seek to "normalize" such mental illnesses through emphasizing them as "stress reactions within an appropriate environment." Thus, negative attitudes toward these "mental illnesses" may have been reduced among the military com- pared to the general population, as military personnel could perceive the manifestation of symptoms of depression and PTSD as not unusual or even pathological in individuals following exposure to traumatic events.11,18-19
The proposition that people with mental illness should have the same job rights as everyone else revealed signifi- cant difference between the military and the general popu- lation (particularly among males). In one respect this is an intuitive finding, as the reality is that military personnel diagnosed with a mental health problem are restricted from certain high-risk occupations, such as weapon and explo- sives handling and piloting an aircraft.9 The
An age effect has been found in most studies investi- gating stigma in Western populations.14 For example, one follow-up study, which conducted 1,725 interviews with a representative population sample, found that the 16 to 19 years age group held the largest proportion of negative views.23 Regarding a gender effect, that was found in this article, previous findings have been mixed. One study, com- paring the differences in public attitudes toward mental illness in
Strengthsand Limitations
The study suffers from some methodological limitations. The use of two different types of interviewer-administered methods (the military survey was conducted over the tele- phone, whereas the general population survey used face-to- face interviews) may have compromised the comparability of the results. A review comparing biases introduced by using mixed questionnaire modes found fewer differences in studies using different types of interviewer-administered modes compared with different modes (such as face-to-face and self-completed questionnaires).26 However, some studies report differences in social desirability bias when using tele- phone vs. face-to-face questionnaires, with neither mode consistently giving more socially desirable responses. Con- sequently it is difficult to determine how this issue may have affected the results. Within the military sample, the 54+ years age group was small (n = 27), therefore the findings for this age group may not be generalizable to the older military population.
The five statements included in this study were used because they were a subset of the items used within the National survey. The authors acknowledge that the study findings relate to a limited number of attitude items, given that as the primary aim of the military study was to assess treatment for mental illness and access to care.2 Some items may also need revising since their formulation in 199427 such as the fifth statement, which targets only women and refers to mental hospitals that no longer exist as described.
In spite of these issues, both surveys were carried out during the same time period (between 2006 and 2007) and the sampling allowed for subgroup differences of age and gender to be analyzed, which has not been done previously.
Implications
Negative attitudes toward mental illness present a current challenge in the military and the general population. In both groups, young males could benefit from targeted antistigma campaigns and educational programmes. In light of our findings, these initiatives could focus particularly on personnel's concerns around mental illness impacting on their career. Efforts to tackle negative attitudes toward mental illness in the
The less favourable attitudes to mental illness in an occupational setting are of concern as they may impact on military personnel's willingness to seek help for mental health problems. Indeed, the most commonly cited concern resulting from admitting to a mental illness is the perceived negative impact it will have on personnel's career.4,8-9 Modifying these attitudes is likely to be challenging for two reasons. First, because the job rights of military per- sonnel with mental illnesses are in reality restricted as described above, and second, because attitudinal changes require an organizational culture shift which may be diffi- cult to achieve. Therefore, it may be that organizational changes are required before attitudinal changes can be achieved. One suggestion of such a change proposed by Gibbs and colleagues could be to encourage self-referrals for confidential treatment for deployment-related mental illness, with an option for evening or weekend treatment hours.11 The aim would be to reduce the visibility of a soldier's absence from duty and potentially the adverse effects of stigmatizing attitudes among peers. However, effecting an organizational shift is likely to be particularly challenging in the military, in which long-established struc- tures and traditions are embedded in a culture of robust toughness, presenting difficulties for those who counter the culture by seeking help for a mental illness.15 The military is faced with the dilemma of protecting personnel from the genuine risks of employing people with mental illness in certain occupational roles while also ensuring that person- nel do not avoid help-seeking for mental illnesses because of concerns about the impact of a diagnosis on their career.
CONCLUSIONS
Overall, this study found few differences in attitudes toward mental illness expressed by the general population in
ACKNOWLEDGMENTS
The authors thank
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*
[dagger]
1Joint first authors.
2Joint last authors.
doi: 10.7205/MILMED-D-12-00436
Copyright: | (c) 2013 Association of Military Surgeons of the United States |
Wordcount: | 4987 |
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