Oliver Schauman

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.

Stigma- and non-stigma-related treatment barriers to mental healthcare reported by service users and caregivers.

Delayed treatment seeking for people experiencing symptoms of mental illness is common despite available mental healthcare. Poor outcomes are associated with untreated mental illness and caregivers may eventually need to seek help on the service users behalf. More attention has recently focused on the role of stigma in delayed treatment seeking. This study aimed to establish the frequency of stigma- and non-stigma-related treatment barriers reported by 202 service users and 80 caregivers; to compare treatment barriers reported by service users and caregivers; and to investigate demographic predictors of reporting stigma-related treatment barriers. The profile of treatment barriers differed between service users and caregivers. Service users were more likely to report stigma-related treatment barriers than caregivers across all stigma-related items. Service users who were female, had a diagnosis of schizophrenia or with GCSEs (UK qualifications usually obtained at age 16) were significantly more likely to report stigma-related treatment barriers. Caregivers who were female or of Black ethnicities were significantly more likely to report stigma-related treatment barriers. Multifaceted approaches are needed to reduce barriers to treatment seeking for both service users and caregivers, with anti-stigma interventions being of particular importance for the former group.

A decision aid to assist decisions on disclosure of mental health status to an employer: protocol for the CORAL exploratory randomised controlled trial

BackgroundThe UK Equality Act 2010 makes it unlawful for employers to ask health questions before making an offer of employment except in certain circumstances. While the majority of employers would prefer applicants to disclose a mental illness at the application stage, many people either wait until they have accepted the job and then disclose to an occupational health professional, or do not do so at all due to the anticipation of discrimination or a wish for privacy. However, non disclosure precludes the ability to request reasonable adjustments in the workplace or to make a claim of direct discrimination. Disclosure to employers is therefore a difficult decision. A recent pilot study by our group of the CORAL decision aid showed that it helped mental health service users clarify their needs and values regarding disclosure and led to reduction in decisional conflict. The present proof of concept trial aims to determine whether a full scale randomised controlled trial (RCT) is justifiable and feasible, and to optimise its design.MethodsIn this single blind exploratory RCT in London, a total of 80 participants (inclusion criteria: age ≥18 years, on the caseload of a specialist employment adviser working with people with mental illness; referred to the adviser either from primary care via Improving Access to Psychological Therapies or secondary mental health service; currently seeking or interested in either paid or voluntary employment, and a Decisional Conflict Scale score of 37.5 or greater and stage of decision score 1–5) will be recruited from vocational advice services. After completing a baseline assessment, participants will be randomly assigned to one of two conditions (1) Use of the CORAL Decision Aid (DA) in addition to treatment as usual or (2) Treatment as usual. Those allocated to the DA condition will be given it to read and complete, and the researcher will be present to record the time taken and any content that causes confusion. Intervention participants may keep the decision aid but are discouraged from showing it to other service users to avoid contamination. Follow up interviews will be conducted at 3 months. Primary outcomes are: (i) stage of decision making score; (ii) decisional conflict scores and (iii) employment related outcomes. Secondary analyses will identify predictors of disclosure and qualitative analysis will explore the impact of the intervention.DiscussionA reduction in decisional conflict regarding disclosure leading to more effective job seeking activity could have significant economic consequences for people with mental illness in terms of employment rates and productivity.Trial registration numberNCT01379014 (ClinicalTrials.gov Identifier)

Mental Illness Related Discrimination: The Role of Self-Devaluation and Anticipated Discrimination for Decreased Well-Being.

People with serious mental illness experience discrimination across many different contexts. Mental illness-related discrimination has, however, been an underresearched area until the last decade. This study aims is to expand understanding of the relationship between discrimination and well-being. Cross-sectional data on stigma, experiences of discrimination, and well-being were collected from adults in specialist mental health services in South London, United Kingdom as part of the Mental Illness-Related Investigations on Discrimination (MIRIAD) study. Structural equation modeling (SEM) supported the predictions that a higher degree of experienced discrimination would be associated with lower well-being via a pathway through higher internalized stigma and hopelessness. Higher anticipated discrimination also separately mediated the association between higher discrimination and lower well-being in the model. This suggests that discrimination is associated with lower well-being through both internalization of negative stereotypes and demoralization, as well as anticipation of further discrimination. In order to increase the well-being of people with severe mental illness (SMI), interventions may need to address the negative beliefs people hold about themselves (internalized stigma), as well as the sense of current and future threat that they experience (experienced and anticipated discrimination).