Lay people's attitudes to treatment of depression: results of opinion poll for Defeat Depression Campaign just before its launchBMJ 1996; 313 doi: http://dx.doi.org/10.1136/bmj.313.7061.858 (Published 05 October 1996) Cite this as: BMJ 1996;313:858
- Robert G Priest, professora,
- Christine Vize, lecturera,
- Ann Roberts, senior registrara,
- Megan Roberts, senior registrarb,
- Andre Tylee, directorc
- a Department of Psychiatry, Imperial College School of Medicine at St Mary's, Paterson Centre, London W2 1PD,
- b John Connolly Unit, Ealing Hospital, Southall UB1 3EU,
- c Royal College of General Practitioners Unit for Mental Health, Division of General Practice and Primary Care, St George's Hospital Medical School, London SW17 0RE
- Correspondence and requests for reprints to: Professor Priest.
- Accepted 17 June 1996
Objective: To investigate the attitudes of the general public towards depression before the Defeat Depression Campaign of the Royal Colleges of Psychiatrists and General Practitioners; these results form the baseline to assess the change in attitudes brought about by the campaign.
Design: Group discussions generated data for initial qualitative research. The quantitative survey comprised a doorstep survey of 2003 people in 143 places around the United Kingdom.
Results: The lay public in general seemed to be sympathetic to those with depression but reluctant to consult. Most (1704 (85%)) believed counselling to be effective but were against antidepressants. Many subjects (1563 (78%)) regarded antidepressants as addictive.
Conclusions: Although people are sympathetic towards those with depression, they may project their prejudices about depression on to the medical profession. Doctors have an important role in educating the public about depression and the rationale for antidepressant treatment. In particular, patients should know that dependence is not a problem with antidepressants.
Before beginning its five year task the campaign sought opinions from 2003 members of the public
Most of the sample (78%) thought that antidepressants were addictive, and only 16% thought that they should be given to depressed people
Most patients treated with antidepressants in primary care abandon taking them prematurely; fear of dependence is one likely explanation
Patients should be informed clearly when antidepressants are first prescribed that discontinuing treatment in due course will not be a problem
The Defeat Depression Campaign is being conducted by the Royal College of Psychiatrists in association with the Royal College of General Practitioners.1 2 3 The royal colleges are concerned that patients do not receive treatment for the depressive illnesses from which they suffer, apparently for two main reasons. Firstly, about 50% of people with depressive illness do not consult their family doctor. Secondly, general practitioners do not always recognise depression.4
A consensus statement was published in the BMJ in November 1992.1 The campaign wished to assess public attitudes to know which attitudes needed to change and to measure the effectiveness of the campaign in promoting those changes. This was done by commissioning an opinion survey before the campaign started and making plans to repeat it at the end of the campaign. A pilot qualitative survey was followed by a quantitative survey; we report the results of these two surveys.
Subjects and methods QUALITATIVE SURVEY
Skilled interviewers from Research Quorum, a market research company in Basingstoke, Hampshire, conducted eight group discussions, with eight people on each panel. Each group was balanced for sex, age, and socioeconomic status. Within the numbers of people sampled, a selection bias clearly cannot be discounted. However, the aim of this qualitative survey was not to obtain accurate percentages for statistical analysis but to clarify potential questions for the larger representative quantitative survey that followed.
Background factors, such as the awareness of various forms of psychiatric disorder, were explored first. The discussion then moved on to depression specifically and explored the participant's understanding of the term, the types of people who suffer from it, and the reasons for and consequences of depression. The final part of the discussion looked at the diagnosis and treatment of depression.
A weighted sample of 2003 people were interviewed by the Market and Opinion Research Institute (MORI) in a door to door survey.5 A total of 143 random sampling points were selected using a system based on parliamentary constituencies across Great Britain. Within each sampling point, respondents were selected according to a rigorous quota system of sex within work status,6 age, and social class. This ensured that an appropriate proportion of working men were included and necessitated making a majority of home visits outside the working day. Over half of the total sample (1096 out of 2003 (55%)) had either suffered from depression themselves or been in contact with someone who had.
The information was gathered using a combination of direct questions and show cards (for graduated answers) based on issues brought up in the quantitative survey. The questions were designed to display a spread of answers so that any shift in opinion might be detected at the end of the campaign. The show cards asked the respondent how strongly he or she agreed or disagreed with a series of statements (strongly agree, tend to agree, neither agree nor disagree, tend to disagree, strongly disagree, don't know).
There was no consensus on what constituted psychiatric disorder, but most people had heard of phobias, schizophrenia, manic depression, and the word psychosis. When the discussion moved on to depression itself most mentioned the symptoms of weepiness, irritability, feeling low, inability to cope, and loss of appetite. Manic depression held the connotation of being a danger to oneself or others.
The causes of depression were perceived as including bereavement, moving house, isolation, marriage breakdown, having a baby, illness, and redundancy. There was a general reluctance to consult general practitioners about emotional problems, but nevertheless most people considered the family doctor to be the most appropriate person to deal with depression initially. Most considered psychiatrists to be the best option for severe depression. However, the word psychiatrist carried connotations of stigma and even fear.
Most participants thought that drug treatment for depression was potentially addictive and dulled the symptoms rather than solving the problem. The most appropriate treatment was considered to be counselling, particularly in group therapy (so that experiences could be shared).
The detailed quantitative survey generally bore out the more impressionistic findings of the qualitative study. The cause of depression was thought to be due to life events such as unemployment (mentioned by 1545 (77%)), a death in the family (1546 (77%)), or a relationship breakdown (1347 (67%)). However, these views did not prevent most respondents (1459 (73%)) from agreeing that depression was a medical condition like a physical illness.
When asked who they would consult about their own depression (if they were to suffer), 1209 (60%) spontaneously mentioned their general practitioner; this number rose to 1589 (79%) when participants were prompted. However, 1203 people (60%) thought that people with depression would be embarrassed to consult their general practitioner. This opinion seemed to be because the general practitioner might regard them as unbalanced or neurotic (1007 (50%)) or that he or she would be irritated or annoyed by it (456 (23%)).
The main treatment favoured was counselling. Most (1827 (91%)) respondents thought that people suffering from depression should be offered counselling, and a mere 324 (16%) thought that they should be offered antidepressants. Most (1704 (85%)) believed counselling to be an effective treatment for depression. Less than half (916 (46%)) said that antidepressants were effective, and nearly a third (602 (30%)) thought that they were not at all effective or at best not very effective. About a quarter of respondents (481 (24%)) did not have an answer to the questions on efficacy. Most (1563 (78%)) considered that antidepressants were addictive, and only 125 (6%) said that they were not, the remainder answering don't know. Even more (1744 (87%)) believed tranquillisers to be addictive, and 794 (40%) thought that tranquillisers would be an effective treatment for depression.
Stigma is still associated with depression. This was shown most clearly in these surveys by the ambivalence in consulting a family doctor. The respondents may be projecting their feelings on to their general practitioner when they say that doctors think that depressed patients are unbalanced or neurotic and therefore irritating or annoying. The information on public attitudes from these surveys enables us to clarify the improvements in lay attitudes that we should like to see as a result of the Defeat Depression Campaign. Also, doctors need to ensure that they do not stigmatise colleagues who suffer from depression or other forms of mental illness. Articles bringing this uncomfortable angle into the open7 are bound to help, but sadly not all people with depression feel confident enough to put their names to their experiences.8
Do so many people really regard antidepressants as addictive? Many lay people may have been extrapolating from what they had heard about benzodiazepine tranquillisers. Nevertheless, whatever its origins, this attitude could have very important implications for doctors when they treat patients with antidepressants. As a result of the consensus meeting1 we are advising that patients who have had a full remission while taking antidepressant drugs should continue to take them for a further four to six months to avoid having a relapse. This applies even to first episode depression in general practice. The median length of time that patients in primary care take their antidepressants seems to be around three weeks.9 Patients may believe that the drugs are addictive so naturally they do not wish to take them for a long time. Doctors should probably do more than they do currently to explore this possibility with the patient when starting antidepressant treatment.
The prescribing patterns of antidepressants by general practitioners in the United Kingdom in 1993 have recently been investigated.10 Older tricyclic antidepressants are prescribed by general practitioners, mainly at doses considered by the consensus statements to be ineffective. This study did not address the issue of length of treatment, and further research is needed as the main information is now over 20 years old.9
Our survey was carried out in December 1991, just before the launch of the Defeat Depression Campaign in January 1992. Since then new antidepressants have had a great deal of publicity and have been increasingly prescribed in primary care. This development, together with the activities of the campaign itself, may have a had a considerable impact on the variables described. We look forward to seeing the findings of a further survey at the end of this campaign.
We thank all members of the Defeat Depression Campaign Management and Scientific Committees who contributed towards the MORI questionnaire and its evaluation.
Funding Defeat Depression Campaign Charity Fund.
Conflict of interest None.