June S. L. Brown

What is the impact of mental health-related stigma on help-seeking?: A systematic review of quantitative and qualitative studies

BACKGROUND Individuals often avoid or delay seeking professional help for mental health problems. Stigma may be a key deterrent to help-seeking but this has not been reviewed systematically. Our systematic review addressed the overarching question: What is the impact of mental health-related stigma on help-seeking for mental health problems? Subquestions were: (a) What is the size and direction of any association between stigma and help-seeking? (b) To what extent is stigma identified as a barrier to help-seeking? (c) What processes underlie the relationship between stigma and help-seeking? (d) Are there population groups for which stigma disproportionately deters help-seeking? METHOD Five electronic databases were searched from 1980 to 2011 and references of reviews checked. A meta-synthesis of quantitative and qualitative studies, comprising three parallel narrative syntheses and subgroup analyses, was conducted. RESULTS The review identified 144 studies with 90,189 participants meeting inclusion criteria. The median association between stigma and help-seeking was d = - 0.27, with internalized and treatment stigma being most often associated with reduced help-seeking. Stigma was the fourth highest ranked barrier to help-seeking, with disclosure concerns the most commonly reported stigma barrier. A detailed conceptual model was derived that describes the processes contributing to, and counteracting, the deterrent effect of stigma on help-seeking. Ethnic minorities, youth, men and those in military and health professions were disproportionately deterred by stigma. CONCLUSIONS Stigma has a small- to moderate-sized negative effect on help-seeking. Review findings can be used to help inform the design of interventions to increase help-seeking.

A Randomized, Placebo-Controlled Trial of Online Cognitive Behavioral Therapy for Chronic Insomnia Disorder Delivered via an Automated Media-Rich Web Application

STUDY OBJECTIVES The internet provides a pervasive milieu for healthcare delivery. The purpose of this study was to determine the effectiveness of a novel web-based cognitive behavioral therapy (CBT) course delivered by an automated virtual therapist, when compared with a credible placebo; an approach required because web products may be intrinsically engaging, and vulnerable to placebo response. DESIGN Randomized, placebo-controlled trial comprising 3 arms: CBT, imagery relief therapy (IRT: placebo), treatment as usual (TAU). SETTING Online community of participants in the UK. PARTICIPANTS One hundred sixty-four adults (120 F: [mean age 49y (18-78y)] meeting proposed DSM-5 criteria for Insomnia Disorder, randomly assigned to CBT (n = 55; 40 F), IRT placebo (n = 55; 42 F) or TAU (n = 54; 38 F). INTERVENTIONS CBT and IRT each comprised 6 online sessions delivered by an animated personal therapist, with automated web and email support. Participants also had access to a video library/back catalogue of session content and Wikipedia style articles. Online CBT users had access to a moderated social network/community of users. TAU comprised no restrictions on usual care and access to an online sleep diary. MEASUREMENTS AND RESULTS Major assessments at baseline, post-treatment, and at follow-up 8-weeks post-treatment; outcomes appraised by online sleep diaries and clinical status. On the primary endpoint of sleep efficiency (SE; total time asleep expressed as a percentage of the total time spent in bed), online CBT was associated with sustained improvement at post-treatment (+20%) relative to both TAU (+6%; d = 0.95) and IRT (+6%: d = 1.06), and at 8 weeks (+20%) relative to IRT (+7%: d = 1.00) and TAU (+9%: d = 0.69) These findings were mirrored across a range of sleep diary measures. Clinical benefits of CBT were evidenced by modest superiority over placebo on daytime outcomes (d = 0.23-0.37) and by substantial improved sleep-wake functioning on the Sleep Condition Indicator (range of d = 0.77-1.20). Three-quarters of CBT participants (76% [CBT] vs. 29% [IRT] and 18% [TAU]) completed treatment with SE > 80%, more than half (55% [CBT] vs. 17% [IRT] and 8% [TAU]) with SE > 85%, and over one-third (38% [CBT] vs. 6% [IRT] and 0% [TAU]) with SE > 90%; these improvements were largely maintained during follow-up. CONCLUSION CBT delivered using a media-rich web application with automated support and a community forum is effective in improving the sleep and associated daytime functioning of adults with insomnia disorder. CLINICAL TRIAL REGISTRATION ISRCTN - 44615689.

Reluctance to seek help and the perception of anxiety and depression in the United kingdom: a pilot vignette study.

We investigated if reluctance to seek help could be explained by how people perceive an illness. Participants were members of the general public who had experienced mental health problems, for which approximately half had sought professional help. We asked them to rate the problems of 2 vignette characters using the Brief Illness Perception Questionnaire (BIPQ). Participants who had sought help were more likely to see the problems of the vignette characters as having more serious consequences and to understand their problems better, compared with those who had not sought help. The depression vignette character was seen as having a problem that was more serious but less amenable to treatment compared with the anxiety vignette character. Compared with men, women were likely to be more aware of the consequences and chronicity of depression. We conclude illness perceptions may help explain reluctance to seek help and discuss implications for encouraging consultation.

Seeking informal and formal help for mental health problems in the community: a secondary analysis from a psychiatric morbidity survey in South London

BackgroundOnly 30-35% of people with mental health problems seek help from professionals. Informal help, usually from friends, family and religious leaders, is often sought but is under-researched. This study aimed to contrast patterns of informal and formal help-seeking using data from a community psychiatric morbidity survey (n=1692) (South East London Community Health (SELCOH) Study).MethodsPatterns of help-seeking were analysed by clinical, sociodemographic and socioeconomic indicators. Factors associated with informal and formal help-seeking were investigated using logistic regression. Cross-tabulations examined informal help-seeking patterns from different sources.Results‘Cases’ (n = 386) were participants who had scores of ≥ 12 on the Revised Clinical Interview Schedule (CIS-R), indicating a common mental disorder. Of these, 40.1% had sought formal help, (of whom three-quarters (29%) had also sought informal help), 33.6% had sought informal help only and only 26.3% had sought no help. When controlling for non-clinical variables, severity, depression, suicidal ideas, functioning and longstanding illnesses were associated with formal rather than informal help-seeking. Age and ethnic group influenced sources of informal help used. Younger people most frequently sought informal help only whereas older people tended to seek help from their family. There were ethnic group differences in whether help was sought from friends, family or religious leaders.ConclusionsThis study has shown how frequently informal help is used, whether in conjunction with formal help or not. Among the ‘cases’, over 60% had sought informal help, whether on its own or together with formal help. Severity was associated with formal help-seeking. Patterns of informal help use have been found. The use and effectiveness of informal help merit urgent research.

The effectiveness of community day-long CBT-I workshops for participants with insomnia symptoms: a randomised controlled trial.

Insomnia is a very common and disabling symptom. Whilst evidence for the efficacy of cognitive behavioural therapy for people diagnosed with insomnia (CBT‐I) is strong, few people seek help and not many services offer CBT‐I. Less intensive adaptations of CBT‐I have been shown to be valuable, and given the size of the problem and low rates of help‐seeking, an accessible intervention with a large capacity is needed. Day‐long CBT‐I psycho‐educational workshops (each for up to 30 people), to which members of the public with insomnia symptoms could self‐refer, have been developed. This randomised controlled trial aimed to evaluate the effectiveness of these workshops. Baseline measures were taken from 151 participants, who were then randomised to experimental or waiting‐list control groups. Scores of the experimental group and the control group were compared 3 months after baseline. Random effects models found a significant interaction between time and group, indicating differences between the control and experimental groups on the Insomnia Severity Index (ISI). Post hoc analyses indicated that ISI scores decreased significantly in the experimental group, but not in the control group. Promising results were also found on corroborative sleep diary measures. Access to the workshops was good, with 50% of participants having never previously sought help for sleep difficulties from their GP. CBT‐I workshops proved to be both accessible and effective in reducing insomnia symptoms in the medium term. They may represent a feasible brief intervention with the potential to address unmet treatment needs of adults complaining of insomnia symptoms.

How black African and white British women perceive depression and help-seeking: a pilot vignette study

Background: The detection of psychological problems of black African people has been found to be substantially lower, compared with white British and black Caribbean people. This may be due to differences in patients’ perceptions of illness. Little research has been carried out on factors that may influence the help-seeking behaviour of black Africans. Aims: To assess differences in the perceptions of depression of black African and white British women that may influence lower detection and to investigate whether there are ethnic group differences in reasons for not seeking formal help. Methods: A short quantitative illness perception measure, the Brief Illness Perception Questionnaire (BIPQ), was used in a community survey, using a standard text vignette methodology to control for variations in previous experiences of depression. Responses from women who indicated that they would not seek formal help for depressive symptoms were qualitatively analyzed. Results: Differences in perceptions of depression were found between black African (n = 73) and white British groups (n = 72) on five of the nine BIPQ dimensions. Black women were more likely to perceive depression to have less serious consequences; to be associated with fewer symptoms; to be less chronic; to be less amenable to treatment; and more frequently attributed depression to social factors. Over half the participants (n = 74) said they would not seek formal help for depressive symptoms. Six qualitative response categories emerged to explain non-consultation. The most common factor for both groups related to GP consultation difficulties. Significantly more white women cited preferring alternative help sources as a reason for non-consultation. The greater number of black women citing anti-medication beliefs was marginally significant. There were no differences between the ethnic groups in their use of the remaining three categories: illness characteristics; service constraints; and stigma/shame. Conclusion: Differing perceptions of depression among black and white women could help explain GPs’ lower detection rates of depressive problems of black women. Differences in views about the formal help available may explain ethnic differences in help-seeking.

Are self-referrers just the worried well? : A cross-sectional study of self-referrers to community psycho-educational Stress and Self-Confidence workshops

Reluctance to seek formal help has been seen as a major problem in trying to reduce the prevalence of anxiety and depression. The aims of this study were to assess the psychiatric status of those self-referring to psycho-educational Stress and Self-Confidence community workshops using a cognitive behavioural therapy (CBT) approach. Cross-sectional analysis of 196 people who referred themselves to community workshops was carried out using the Clinical Interview Schedule (CIS-R) psychiatric interview and the Beck Depression Inventory (BDI) and Spielberger Trait Anxiety Inventory (STAI-T) scale self-report assessments. Over 70% of all self-referrers had an ICD-10 diagnosis. Those without diagnoses had experienced recurrent significant psychological problems and 29.7% had never consulted their General Practitioner (GP) for anxiety/depression problems. Total CIS-R scores and white ethnic group best predicted previous GP consultation. Setting up a self-referral system can enable those with diagnosable psychiatric problems, who may otherwise be reluctant to seek help, to come forward. This may have significant public mental health implications.

What are we doing to waiting list controls

For ethical reasons waiting list controls have been preferred to no treatment controls, provided the wait is still shorter than that for routine services. However, could significant differences arise from the wait being detrimental rather than the intervention being beneficial? Despite the number of studies employing this design, few have analysed intervention trials from the perspective of the waiting list controls rather than the experimental group. A Full Day Stress Management Workshop programme which had run successfully in Birmingham, was repeated in three areas in the South East of England. The data from the four areas were reanalysed to assess progress within the control group and to compare the final assessment points for the two groups. The control group did not show any significant deterioration during the three month wait for their workshop. Three months after their respective workshops, scores in the control groups did not differ significantly from those of the experimental group.

Large-scale health promotion stress workshops: Promotion, programme content and client response

A series of stress m anagem ent workshops open to m em bers of the general public was run in support of a city-wide health promotion campaign on reducing stress. To increase access, workshops were run in a leisure centre at weekends over either one whole day or two half-days. Care was taken to design the workshop structure so as to not exhaust or bore people while teaching a range of skills to help participants m anage stress. A large number of enquiries was received in response to the prom otion of the workshops. The characteristics of those who self-referred are described, as are the workshop program me and its acceptability. Client satisfaction with the workshops was high and the drop-out rate

Meeting the needs for psychological treatment of people with common mental disorders: an exploratory study

This paper describes the limited availability of resources for common mental disorders and the unmet need for treatment for both anxiety and depression. A specific focus is to consider whether a self-referral approach to Stress can be adapted to meet the unmet need for treatment of people with depression. Results indicate that the take-up for a self-referral Depression workshop is much lower than that for the Stress workshops, particularly between the enquiry and the Introductory Talk stage. Additionally, those who came to the Introductory Talks for the Depression workshops were very similar to psychology service referrals. Over 90% had previously been to see their GP, been diagnosed and referred on to the specialist mental health services. It was concluded that the self-referral mechanism was not successful in meeting the unmet needs of those with depression who had not been previously referred. Suggestions are made about improving take-up and engagement for this group.