Nisha Mehta

Evidence for effective interventions to reduce mental-health-related stigma and discrimination

Stigma and discrimination in relation to mental illnesses have been described as having worse consequences than the conditions themselves. Most medical literature in this area of research has been descriptive and has focused on attitudes towards people with mental illness rather than on interventions to reduce stigma. In this narrative Review, we summarise what is known globally from published systematic reviews and primary data on effective interventions intended to reduce mental-illness-related stigma or discrimination. The main findings emerging from this narrative overview are that: (1) at the population level there is a fairly consistent pattern of short-term benefits for positive attitude change, and some lesser evidence for knowledge improvement; (2) for people with mental illness, some group-level anti-stigma inventions show promise and merit further assessment; (3) for specific target groups, such as students, social-contact-based interventions usually achieve short-term (but less clearly long-term) attitudinal improvements, and less often produce knowledge gains; (4) this is a heterogeneous field of study with few strong study designs with large sample sizes; (5) research from low-income and middle-income countries is conspicuous by its relative absence; (6) caution needs to be exercised in not overgeneralising lessons from one target group to another; (7) there is a clear need for studies with longer-term follow-up to assess whether initial gains are sustained or attenuated, and whether booster doses of the intervention are needed to maintain progress; (8) few studies in any part of the world have focused on either the service users perspective of stigma and discrimination or on the behaviour domain of behavioural change, either by people with or without mental illness in the complex processes of stigmatisation. We found that social contact is the most effective type of intervention to improve stigma-related knowledge and attitudes in the short term. However, the evidence for longer-term benefit of such social contact to reduce stigma is weak. In view of the magnitude of challenges that result from mental health stigma and discrimination, a concerted effort is needed to fund methodologically strong research that will provide robust evidence to support decisions on investment in interventions to reduce stigma.

Evidence for effective interventions to reduce mental health-related stigma and discrimination in the medium and long term: systematic review

Background Most research on interventions to counter stigma and discrimination has focused on short-term outcomes and has been conducted in high-income settings. Aims To synthesise what is known globally about effective interventions to reduce mental illness-based stigma and discrimination, in relation first to effectiveness in the medium and long term (minimum 4 weeks), and second to interventions in low- and middle-income countries (LMICs). Method We searched six databases from 1980 to 2013 and conducted a multi-language Google search for quantitative studies addressing the research questions. Effect sizes were calculated from eligible studies where possible, and narrative syntheses conducted. Subgroup analysis compared interventions with and without social contact. Results Eighty studies (n = 422 653) were included in the review. For studies with medium or long-term follow-up (72, of which 21 had calculable effect sizes) median standardised mean differences were 0.54 for knowledge and −0.26 for stigmatising attitudes. Those containing social contact (direct or indirect) were not more effective than those without. The 11 LMIC studies were all from middle-income countries. Effect sizes were rarely calculable for behavioural outcomes or in LMIC studies. Conclusions There is modest evidence for the effectiveness of anti-stigma interventions beyond 4 weeks follow-up in terms of increasing knowledge and reducing stigmatising attitudes. Evidence does not support the view that social contact is the more effective type of intervention for improving attitudes in the medium to long term. Methodologically strong research is needed on which to base decisions on investment in stigma-reducing interventions.

Impact of the “Like Minds, Like Mine” anti-stigma and discrimination campaign in New Zealand on anticipated and experienced discrimination

Objective: The “Like Minds, Like Mine” anti-stigma and discrimination programme has been running in New Zealand since 1997. We aimed to investigate the nature and degree of anticipated and experienced discrimination reported by people with mental illness, and their views on whether the campaign was contributing to reductions in stigma and discrimination. Methods: Questionnaires were sent to randomly selected people who were representative of those who had recently used mental health services in New Zealand. The measure used was the modified Discrimination and Stigma Scale (DISC-12), adding questions on the effect of “Like Minds, Like Mine”, and also assessing overall changes in discrimination in the previous 5 years. Results: A total of 1135 participants completed the questionnaire. This included 225 Ma–ori, 196 Pacific, and 152 Asian persons. Over half of all participants reported improvement in discrimination over the previous 5 years, and 48% thought that the “Like Minds Like Mine” programme had assisted in reducing discrimination “moderately” or “a lot”. Nevertheless, a clear majority (89%) reported experiencing at least “a little” unfair treatment in the previous 12 months due to their mental health problems. The primary source of both positive and negative discrimination was the family. Many (57%) participants had concealed or hidden their mental health problems from others, and 33% had stopped themselves from applying for work because they anticipated discrimination. Conclusions: Family, friendship, and social life were the most common areas of discrimination reported by the participants; however, many believed the overall level of discrimination had reduced over the previous 5 years. Overall, these results characterize the nature of stigma and discrimination anticipated and experienced by people with mental health problems and indicate modest but clear and positive recent progress in their reduction.

Public mental health: evidenced-based priorities.

1This report, similarly to others before it, brings together the best evidence about mental health and is set within a contemporary policy context that informs the Chief Medical Offi cer’s recommendations. Unlike many other areas of health, public mental health is diffi cult to defi ne because there are contested boundaries and terminology. Although the varied landscape is undoubtedly a potential strength, we are concerned by an inability to agree about fundamental issues in this broad fi eld. These issues include the defi nition and key components of public mental health; the relation of concepts within mental health to one another; how mental health variations of importance are measured and experienced; the value placed o n mental health and its consistency across society; and our approach to the generation, accumulation, and assessment of evidence and policy in public mental health. We discuss these topics further in the Chief Medical Offi cer’s Annual Report, in a chapter written by S Davies and N Mehta, who are also authors of this Viewpoint. 1

Stigmatisation of People with Mental Illness and of Psychiatric Institutions

The effects of stigmatisation upon people with mental illness are common and profoundly socially excluding, and so constitute unethical barriers to full social participation. This chapter will therefore discuss the ethical dimension of stigma by defining terms, discussing the existing literature on stigma related to mental illness, considering global patterns of stigma, and examining stigma and human rights within psychiatric institutions.

Satisfaction with psychiatric in-patient care as rated by patients at discharge from hospitals in 11 countries

PurposeThere is disregard in the scientific literature for the evaluation of psychiatric in-patient care as rated directly by patients. In this context, we aimed to explore satisfaction of people treated in mental health in-patient facilities. The project was a part of the Young Psychiatrist Program by the Association for the Improvement of Mental Health Programmes.MethodsThis is an international multicentre cross-sectional study conducted in 25 hospitals across 11 countries. The research team at each study site approached a consecutive target sample of 30 discharged patients to measure their satisfaction using the five-item study-specific questionnaire. Individual and institution level correlates of ‘low satisfaction’ were examined by comparisons of binary and multivariate associations in multilevel regression models.ResultsA final study sample consisted of 673 participants. Total satisfaction scores were highly skewed towards the upper end of the scale, with a median total score of 44 (interquartile range 38–48) out of 50. After taking clustering into account, the only independent correlates of low satisfaction were schizophrenia diagnosis and low psychiatrist to patient ratio.ConclusionFurther studies on patients’ satisfaction should additionally pay attention to treatment expectations formed by the previous experience of treatment, service-related knowledge, stigma and patients’ disempowerment, and power imbalance.