Bipolar4LifeSupport

Introduction

Studies have demonstrated relationships between physical health and mental health (1,2). Chronic disease has been associated with depression, which, in the absence of intervention, also can assume a chronic course (3). To determine the prevalence of depression among adults in New Mexico and examine the association between depression and selected health risk behaviors and health conditions, the New Mexico Department of Health and CDC analyzed data from the 2003 New Mexico Behavioral Risk Factor Surveillance System (BRFSS) survey. This report describes the results of that analysis, which determined that 3.8% of adults in New Mexico had current symptoms of depression and that these adults were significantly more likely to have engaged in certain health risk behaviors (e.g., smoking and binge drinking) and to have certain health conditions (e.g., high blood pressure, high blood cholesterol, arthritis, and asthma) than persons without depression. Public health programs that promote mental health and timely diagnosis and treatment of depression might also help reduce morbidity and risk behaviors related to chronic diseases.

New Mexico BRFSS is a state-based component of the CDC BRFSS, through which states conduct random-digit–dialed telephone surveys of their noninstitutionalized, civilian population aged >18 years. In 2003, a total of 5,494 adults participated in the New Mexico survey; the CASRO response rate was 56.4%.

The New Mexico survey included six questions adapted from the Primary Care Evaluation of Mental Disorders (PRIME-MD) to assess the prevalence of depression among adults in the state. Two screening questions were asked: “During the past 30 days, have you often been bothered by feeling down, depressed, or hopeless?” and “During the past 30 days, have you often been bothered by little interest or pleasure in doing things?” (4). Respondents who answered “yes” to either screening question were then asked the other four core depressive symptom questions. Respondents were asked how often during the preceding 14 days they had been “bothered by little interest or pleasure in doing things,” “bothered by trouble falling or staying asleep, or sleeping too much,” “bothered by poor appetite or overeating,” and “bothered by feeling bad about yourself, or that you are a failure or have let yourself or your family down” (5). Participants chose from the following four responses: “not at all,” “several days,” “more than half of the days,” and “nearly every day.” Respondents were considered depressed if they answered “yes” to either of the two PRIME-MD screening questions and “nearly every day” to two or more of the four questions regarding depressive symptoms (4). Data were weighted to reflect the demographic profile of the noninstitutionalized civilian population of New Mexico. Differences in point estimates were considered not significant if their 95% confidence intervals (CIs) overlapped.

The overall prevalence of depression among adults in New Mexico was 3.8% (CI = 3.2%–4.5%) and varied significantly by age, race/ethnicity, income, and education but not by sex. Results of age-group analysis indicated that persons aged 45–54 years (4.9%; CI = 3.4%–6.8%) were most likely to be depressed and that those aged >75 years (1.7%; CI = 0.9%–3.2%) were least likely to be depressed. Among racial/ethnic groups, prevalence of depression ranged from 4.9% (CI = 3.8%–6.1%) among Hispanics to 1.8% (CI = 0.6%–5.2%) among American Indians/Alaska Natives. By income, persons with annual household incomes of <$10,000 had the highest prevalence of depression (12.7%; CI = 8.6%–18.4%), and those with incomes of >$50,000 had the lowest prevalence (1.4%; CI = 0.9%–2.2%). By education level, adults who had not graduated from high school had the highest prevalence of depression (7.8%; CI = 5.6%–11.0%), and those who had graduated from college had the lowest prevalence (1.7%; CI = 1.1%–2.5%).

Adults with depression were significantly more likely than those without depression to report the following health risk behaviors or health conditions*: fair or poor general health (53.8% versus 15.2%), no moderate or vigorous physical activity (26.2% versus 7.8%), current smoking (54.4% versus 20.7%), binge drinking (24.9% versus 14.5%), obesity (29.9% versus 20.1%), high blood pressure (30.9% versus 20.9%), and high blood cholesterol (40.7% versus 26.9%). However, no significant difference was determined for those with or without diabetes (Table).

Reported by: J Daniel, MPH, W Honey, MPH, M Landen, MD, New Mexico Dept of Health. S Marshall-Williams, PhD, D Chapman, PhD, J Lando, MD, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

The findings in this report indicate that, in New Mexico, certain adverse health risk behaviors and health conditions are more common among persons with depression than among persons without depression, underscoring the importance of considering mental health in the prevention and treatment of chronic illnesses. Among the risk behaviors and conditions considered, the findings from this study did not indicate a significant relationship between diabetes and depression, which is consistent with the results of a previous study (6) but inconsistent with the results of another (7). In addition, the overall estimated 3.8% prevalence of depression is lower than the 6.7% prevalence estimated by the U.S. National Comorbidity Survey Replication. However, the prevalence in this report was based on telephone interviews with participants regarding depressive symptoms that occurred during the preceding 14 days; the national comorbidity survey prevalence came from symptoms that occurred during a 12-month period, based on face-to-face interviews conducted during 2001–2003 (8).

The findings in this report are subject to at least four limitations. First, the data on which they were based were self-reported by telephone survey and might have been different had they been obtained by physical and psychiatric examination. Second, data were collected only from noninstititutionalized adult residents with landline telephones; these data might not be generalizable to persons in younger age groups, who might be more likely to use cellular phones exclusively. Third, only residents of New Mexico were surveyed, and results might not be generalizable to persons residing in other regions of the United States. Finally, because these data are cross-sectional, they do not permit any inference of a causal pathway between depression and the physical health risk behaviors and health conditions investigated. Nonetheless, the findings in this report corroborate the correlation between depression and chronic diseases and conditions determined by previous studies (3) and thus suggest that the assessment and treatment of depression can help to improve the overall health of a population.

Although depressive disorders can be treated successfully, data ranging from the Epidemiologic Catchment Area program in the early 1980s to those collected by the 2002 National Health Interview Survey indicated that most persons needing treatment for mental illness did not receive treatment (9). Barriers to treatment include the stigma associated with depression, lack of knowledge about depression, and lack of adequate insurance coverage (2). Persons with depression, particularly those who also have a physical health condition, might seek treatment from various types of health-care professionals (e.g., general practitioners) other than psychiatrists, psychologists, or psychiatric social workers.

The U.S. Preventive Services Task Force (USPSTF) recommends screening adults for depression in clinical practices if systems exist to ensure accurate diagnosis, effective treatment, and follow-up. USPSTF determined that screening increases the accurate identification of depressed patients in primary-care settings and that treatment of depressed adults in primary-care settings decreases their level of clinical morbidity (10). CDC can help increase understanding of depression and its public health burden by conducting mental health surveillance and working with national partners, such as the National Mental Health Association, Substance Abuse and Mental Health Services Administration, and National Institute of Mental Health to address the prevention and treatment of mental illnesses. New Mexico plans to continue its population-based surveillance for depression through BRFSS.

A decade ago, the Surgeon General’s office released its first report on mental health (1), calling for the full integration of mental health into the nation’s public health system. The report synthesized the scientific literature on mental illness, concluding that mental disorders are among the most prevalent and costly conditions and that effective treatments can reduce their prevalence and decrease their adverse effect on other health conditions. The report took a broad public health approach, focusing not only on clinical diagnosis and treatment of mental illness but also on surveillance, prevention, and promotion of mental health (2).

The Surgeon General’s report described research developments from the 1990s, the “Decade of the Brain,” that helped establish the biological underpinnings of mental disorders and move mental health into the mainstream of research and specialty practice. The subsequent decade saw a dramatic rise in the proportion of the US population receiving mental health care (3) and a shift in the locus of treatment for mental illness away from specialty settings and toward primary care (4). During the same period, strategies for moving medical and psychiatric treatment from research into routine practice settings were developed and disseminated. In particular, research showed that integrated approaches could improve quality and outcomes of care in clinical settings on the interface of primary care and mental health (5). This research laid the groundwork for a broader strategy to integrate mental health and public health at a population level. The passage of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 was a step toward this goal.

As the lead government agency for the nation’s public health, the Centers for Disease Control and Prevention (CDC) can play a central role in these efforts to integrate mental health and public health. Articles in this issue of Preventing Chronic Disease were developed by an expert panel convened by CDC’s Division of Adult and Community Health on behalf of the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP). The panel was charged with examining how mental health should fit within NCCDPHP’s mission. The articles provide the background for the panel’s recommendations and cover a spectrum of public health activities, including surveillance, prevention and promotion, and the system and policy context for these proposed changes.

Freeman et al (6) provide a mixed report on the mental health surveillance systems available in the United States. Existing systems offer data about the prevalence and severity of mental disorders in the United States and their relationship to other chronic diseases and health behaviors, but they are limited by differences in methods, priorities, and lack of input from end users. Better coordination across and in the federal agencies that field these surveys could improve the value of the information, reduce redundancy, and increase the use of the data by researchers and policy makers.

Whereas the medical model focuses on understanding and treating disease, public health approaches take a broader view of health that includes both sickness and well-being. Manderscheid et al (7) describe health and illness not as a single continuum, but as distinct states that can exist simultaneously. This premise is compatible with the idea of recovery as a permanent condition that allows people to live fulfilling lives despite ongoing mental or physical symptoms. The recovery model has become central to the mental health advocacy and policy communities and was a guiding principle for the recommendations in the President’s New Freedom Commission report (8). Recovery promotes a strength-based, public health approach that could easily be expanded to many people with chronic medical conditions.

Although public health activities must include surveillance and interventions across large populations, they must also account for differences across regional and cultural subgroups. The supplement to the Surgeon General’s report, Culture, Race, and Ethnicity, noted that even greater racial and ethnic disparities exist for mental health care than for other types of health services (9) and that reducing these disparities will require close attention to issues of racial and cultural diversity. Primm et al (10) note that these disparities result not only from bias but also from social factors such as disadvantages in housing and income. Fully resolving these disparities will therefore require expanding beyond the formal health system and understanding the social determinants of mental health and well-being.

Given the decentralized and complex nature of mental health care, improvements must rely on partnerships at multiple levels. Primary care providers need to work more closely with mental health centers to ensure coordinated treatment (11). Counties need to develop relationships between mental health, medical, and local public health agencies (12). State public health agencies need to work more closely with mental health agencies (13). Finally, federal agencies need to better coordinate their efforts (14). In particular, CDC and the Substance Abuse and Mental Health Services Administration (SAMHSA), which have historically functioned in parallel but unconnected tracks, are now collaborating more closely on activities, such as jointly funding the surveillance of mental health and mental illnesses. Leaders from SAMHSA’s Center for Mental Health Services were represented on the expert panel and are advising NCCDPHP on integrating mental health into its mission.

The nation is now poised to take the next step toward realizing the vision of integrating mental health and public health described a decade ago in the Surgeon General’s report. Spiraling health care costs and the rising number of uninsured Americans have built momentum for health care reform, and it is clear that a population-based, public health approach — one that encompasses mental health — will be needed as a foundation for that reform (15).

Surveillance Data Sources

Health-Related Quality of Life—Behavioral Risk Factor Surveillance System (BRFSS)

The BRFSS is an annual state-based telephone survey of the U.S. civilian, non-institutionalized adult population. The Healthy Days measures used to assess health-related quality of life (HRQOL) have been a part of the BRFSS core questionnaire since 1993. For more details, including the Healthy Days questions and links to the data, refer to the following PDF file.

For public health surveillance purposes, the CDC Health-Related Quality of Life (HRQOL) measures have provided a generic HRQOL index operationalized as a person’s or group’s physical and mental health over time.¹ The data from the mental health questions have been used to calculate frequent mental distress (FMD=14 to 30 mentally unhealthy days in the past 30 days) which has been used as a proxy for poor mental health. The CDC Healthy Days measures were developed with expert input and have been a part of the core BRFSS survey since 1993 and the National Health and Nutrition Examination Survey (NHANES) since 2000.

• BRFSS—Healthy Days/HRQOL-4 questions PDF[19.87 KB].
• For more information on BRFSS: Behavioral Risk Factor Surveillance System (BRFSS).

Kessler 6 (K6) for Serious Psychological Distress—Behavioral Risk Factor Surveillance System (BRFSS)

The BRFSS is an annual state-based telephone survey of the U.S. civilian, non-institutionalized adult population. The Kessler 6 (K6) is a standardized and validated measure of non-specific psychological distress. During 2007 and 2009, K-6 was added as an optional module on the BRFSS and was administered by 26 states, the District of Columbia and Puerto Rico. A score of 10 or more on the K6 is used to indicate non-specific serious psychological distress (SPD). This information can be used as an estimate of the prevalence of serious mental illness (SMI) in community populations2,3. The K6 instrument offers a useful tool for states to assess the potentially unmet mental health needs of a large proportion of adults within their jurisdiction.

• BRFSS—Mental Illness and Stigma Optional Module[PDF-48KB] (includes Kessler 6).
• For more information on the K6 instrument: National Comorbidity Survey.
• For more information on BRFSS: Behavioral Risk Factor Surveillance System (BRFSS).

Health-Related Quality of Life—National Health and Nutrition Examination Survey (NHANES)

NHANES is a program of studies designed to assess the health and nutritional status of adults and children in the United States. The survey is unique in that it combines interviews and physical examinations. The HRQOL-4 questions are included in the Current Health Status questionnaire and are asked of participants age 12 and older. For more details, including the questions and links to the data, refer to the following PDF file.

• NHANES—Healthy Days/HRQOL-4 questions[PDF 20.35KB].
• For more information on NHANES: National Health and Nutrition Examination Survey (NHANES).

Non-Specific Distress Battery—National Health Interview Survey (NHIS)

NHIS data are collected through personal household interviews. The Non-Specific Distress Battery is part of the adult questionnaire and has been administered since 1997. For more details, including the questions that make up the module and links to the data, refer to the following PDF file

• NHIS—Non-Specific Distress Battery[PDF 16.5KB].
• For more information on NHIS: National Health Interview Survey (NHIS).

Statistics

Behavioral Risk Factor Surveillance System Kessler 6 (K6)

For 2007 K6 data, based on a period of “in the past 30 days.”

• Approximately 40% of persons in 35 states had serious psychological distress (SPD, defined as a score of 10 or more on the K6)
• Of respondents indicating they had SPD:
  • 37.7% received mental health services in the preceding year
  • 53.4% currently received no treatment
  • A greater percentage were likely to be women
  • Were more likely to be unmarried
  • Were more likely to live in poverty
• Medically, respondents with SPD were more likely to be obese, to smoke, and to report being diagnosed with heart disease.

Behavioral Risk Factor Surveillance System (BRFSS) Health Related Quality of Life

For 2004–2008 Health-Related Quality of Life (HRQOL) data, based on a period of “in the past 30 days.”

• U.S. adults experienced an average of 3.6 physically unhealthy days.
• U.S. adults experienced an average of 3.4 mentally unhealthy days.
• U.S. adults experienced an average of 6.1 overall unhealthy days.
• U.S. adults experienced an average of 2.2 days of activity limitation.
• An estimated 10.8% of U.S. adults experienced 14 or more physically unhealthy days.
• An estimated 6.7% of U.S. adults experienced 14 or more days of activity limitation.
• An estimated 10.2% of U.S. adults experienced 14 or more mentally unhealthy days (Frequent Mental Distress or FMD).
• The Appalachian and the Mississippi Valley regions have high and increasing FMD prevalence, and the upper Midwest had low and decreasing FMD prevalence.⁴

The figure below presents estimates of the number of respondents on the BRFSS who reported frequent mental distress (14 to 30 mentally unhealthy days in the past 30 days) by county, aggregated over 2003–2009. The prevalence for Alaska is estimated for the state as a whole because Alaska BRFSS did not record county codes. Kalawao County, Hawaii, was excluded as having no respondents. Data are weighted using sampling weights based on the state populations by sex, age group, and race. County-level rates were smoothed using a nonparametric spatial smoothing algorithm⁵. Counties with combined sample sizes (2003–2009) of less than 30 were masked in the accompanying figure.

Negative attitudes about mental illness often underlie stigma, which can cause affected persons to deny symptoms; delay treatment; be excluded from employment, housing, or relationships; and interfere with recovery (1). Understanding attitudes toward mental illness at the state level could help target initiatives to reduce stigma, but state-level data are scant. To study such attitudes, CDC analyzed data from the District of Columbia (DC), Puerto Rico, and the 35 states participating in the 2007 Behavioral Risk Factor Surveillance System (BRFSS) (the most recent data available), which included two questions on attitudes toward mental illness. Most adults (88.6%) agreed with a statement that treatment can help persons with mental illness lead normal lives, but fewer (57.3%) agreed with a statement that people are generally caring and sympathetic to persons with mental illness. Responses to these questions differed by age, sex, race/ethnicity, and education level. Although most adults with mental health symptoms (77.6%) agreed that treatment can help persons with mental illness lead normal lives, fewer persons with symptoms (24.6%) believed that people are caring and sympathetic to persons with mental illness. This report provides the first state-specific estimates of these attitudes and provides a baseline for monitoring trends. Initiatives that can educate the public about how to support persons with mental illness and local programs and media support to decrease negative stereotypes of mental illness can reduce barriers for those seeking or receiving treatment for mental illness (2,3).

To measure attitudes about mental illness through BRFSS and other surveys, the Substance Abuse and Mental Health Services Administration (SAMHSA) and CDC collaborated in 2005 to develop brief questions suitable for surveillance (4). BRFSS is an ongoing, state-based, random-digit–dialed telephone survey of the noninstitutionalized civilian population aged ≥18 years.* With SAMHSA and CDC support, 35 states, DC, and Puerto Rico questioned survey respondents to the 2007 BRFSS about mental illness. Questions included the Kessler-6 scale of serious psychological distress (5), frequent mental distress, one question about current treatment for an emotional problem, and two attitudinal questions.

The Kessler 6-scale asks respondents how often in the past 30 days they felt six symptoms of mental illness (i.e., feeling nervous, depressed, hopeless, restless, like a failure, like everything was an effort). Each item is scored on a 5-point scale indicating frequency, ranging from 0 (none of the time) to 4 (all of the time), and summed (score range: 0–24). Respondents scoring 13 or more on this scale were classified as having serious psychological distress (5). Frequent mental distress was measured with the question, “For how many days in the past 30 days was your mental health (due to stress, depression, or problems with emotions) not good?” Respondents reporting 14 or more poor mental health days were identified as having frequent mental distress. To determine current treatment for an emotional problem, survey participants were asked, “Are you now taking medicine or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem?”

Attitudes were assessed by asking respondents to indicate their level of agreement with two statements. The first statement assessed attitude on the effectiveness of treatment: “Treatment can help people with mental illness lead normal lives.” The second statement assessed the respondent’s perception of others’ attitudes toward persons with mental illness: “People are generally caring and sympathetic to people with mental illness.”† Before inclusion in BRFSS, cognitive testing in a sample of the general population confirmed that adults understood these questions as intended. For example, respondents suggested that “normal lives” meant “being able to do everyday things, like going to the grocery store, paying bills, things that you have to do to live.” The question about attitudes toward treatment also demonstrated acceptable construct validity with expectations regarding mental illness recovery.

Data were weighted to estimate population parameters. CDC used statistical software to calculate unadjusted and adjusted proportions (adjusted for sex, age group, racial/ethnic group, education, and household income) of agreement by state and by serious psychological distress, frequent mental distress, and mental health treatment, and to account for the complex BRFSS survey design. After adjustment, CDC examined differences in proportions across agreement categories for both questions by serious psychological distress, frequent mental distress, and mental health treatment status. The analyses excluded persons who responded “did not know” or “refused” to answer the questions.§ The sample size included 202,065 adults. Among the 35 states, DC, and Puerto Rico, the median Council of American Survey Research Organization (CASRO) response rate was 51% and the CASRO cooperation rate was 71.4%.¶

Most adults agreed, either strongly (62.8%) or slightly (25.8%), that treatment could help persons with mental illness lead normal lives, but responses varied by states (Table 1). The highest percentages of strongly agreeing with this statement were in Connecticut, DC, Louisiana, Oregon, Vermont, Virginia, and Washington; the lowest was in Puerto Rico (Figure). Proportions for neither agree nor disagree ranged from 0.6% (Iowa) to 9.2% (Puerto Rico). Younger adults, men, persons other than white non-Hispanics, and persons at lower education levels were less likely to agree strongly with this statement (Table 2).

In contrast with the statement about treatment, a lower proportion of adults agreed, either strongly (22.3%) or slightly (35.0%), with the statement that people are caring and sympathetic to persons with mental illness (Table 3). The highest percentages of strongly agreeing with this statement occurred in Hawaii, Louisiana, Mississippi, Oklahoma, Nevada, and New Mexico. The lowest was in Puerto Rico. Adults aged 25–54 years, women, white non-Hispanics and black non-Hispanics, and college graduates were less likely to agree with this statement (Table 2).

Approximately 4.0% of adults were classified with serious psychological distress, 10.0% were classified with frequent mental distress, and 10.8% reported receiving treatment for an emotional problem. Although most adults with mental health symptoms (77.6%) agreed strongly or slightly that treatment can help persons with mental illness lead normal lives, about 17.8% disagreed (Table 2). Fewer respondents with mental health symptoms (24.6%) agreed strongly or slightly that people are generally caring and sympathetic to persons with mental illness than those without such distress or treatment (Table 2).

Reported by

R Manderscheid, PhD, National Assoc of County Behavioral Health and Developmental Disability Directors. P Delvecchio, MSW, C Marshall, Center for Mental Health Svcs, Substance Abuse and Mental Health Svcs Admin. RG Palpant, MS, J Bigham, TH Bornemann, EdD, Carter Center Mental Health Program. R Kobau, MPH, MAPP, M Zack, MD, G Langmaid, W Thompson, PhD, D Lubar, MSW, Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

This is the first state-specific study of attitudes toward mental illness treatment and empathy toward persons with mental illness. The study sought to assess attitudes related to the course of mental illness (i.e., treatment prognosis and possibility of recovery; and perception of supportive behaviors) that might directly influence seeking treatment or recovery and might reflect stigmatizing attitudes amenable to public health intervention. In the 37 jurisdictions surveyed, most adults believed in the effectiveness of mental illness treatment, but fewer agreed that people are caring and sympathetic toward persons with mental illness. These results have public health implications because adverse attitudes about mental illness can lead to stigmatization of persons with mental illness. In addition, the results have implications for mental health treatment because adults who do not believe in the effectiveness of mental illness treatment might be less likely to seek treatment when needed. Also, persons with mental health symptoms who believe that others are not caring and sympathetic toward persons with mental illness might be less likely to disclose mental health problems to friends, family members, colleagues, or other persons who could help.

Some of the adverse attitudes indicated in this report might be caused by stigma experienced by some respondents (e.g., those with mental health problems who received less support at work or at home or who experienced exclusion from activities) (6). Respondents who perceived adverse attitudes about empathy in other persons also might have had less contact with persons with mental illness, or also might harbor misconceptions about the risks associated with mental illness symptoms (7).

Although the study did not include all 50 states and U.S. territories, state-to-state differences were noted, but no clear regional patterns emerged on the attitudes studied. Differences might have resulted from culture and the social environment (e.g., norms, customs, language, lifestyle, and degree of acculturation), differences in how mental health is portrayed in various media, and differences in awareness of and access to mental health treatment. Geographic variability in attitudes toward mental illness and its causes should be a topic of further study.

Attitudes toward persons with mental illness appear to be improving in the United States. One study determined that in 2006, compared with previous decades since the 1950s, more U.S. adults believed that mental health problems could improve with treatment (8). The large proportion of adults with positive attitudes toward mental illness treatment in the United States (and in the 37 jurisdictions studied for this report) might result from antistigma campaigns, and greater attention, awareness, and understanding of mental health (9).

One result from the analysis presented in this report was the varying attitudes by education level. For example, adults with greater education were more likely to agree strongly that mental health treatment can help persons with mental illness lead normal lives but were less likely to agree strongly that people can be caring and sympathetic to persons with mental illness. In one study, among some professionals, more knowledge and contact with persons with mental illness was associated with more stigmatizing attitudes (10). Another possibility is that these adults might have experienced less supportive behaviors associated with mental illness (i.e., feel stigmatized) and thus were more likely to report negative attitudes compared with other groups.

The findings in this report are subject to at least four limitations. First, BRFSS surveys include only noninstitutionalized adults with telephones. Persons in institutions and in households without telephones are excluded, and this population might include a higher proportion of persons with mental health symptoms. Second, because states commonly use only English- or Spanish-language surveys, persons who speak other primary languages are excluded, which could affect race- and ethnicity-specific results. Third, because these data are not nationally representative, no conclusions can be drawn about the entire U.S. population. Finally, the question on caring and sympathy requires further validation in terms of understanding its association with other mental health attitudinal measures (4).

Persons with mental illness generally are able to live successful, full lives, particularly if they receive proper treatment and support. To reduce the effects of stigma, public health and mental health agencies can implement local activities to reduce negative attitudes about mental illness (3). Because the media can frame public opinion, they can be important partners in this and in promoting accounts of mental illness recovery (2). Public educational resources, such as those available on SAMHSA’s “What a difference a friend makes” Internet site,** also can reduce negative attitudes toward mental illness by providing information about mental illness and its treatment, and help persons learn how to reassure, be friends with, and accept persons who seek or receive treatment for mental illness.