Silvia Zoppei

Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey

BACKGROUND Depression is the third leading contributor to the worldwide burden of disease. We assessed the nature and severity of experienced and anticipated discrimination reported by adults with major depressive disorder worldwide. Moreover, we investigated whether experienced discrimination is related to clinical history, provision of health care, and disclosure of diagnosis and whether anticipated discrimination is associated with disclosure and previous experiences of discrimination. METHODS In a cross-sectional survey, people with a diagnosis of major depressive disorder were interviewed in 39 sites (35 countries) worldwide with the discrimination and stigma scale (version 12; DISC-12). Other inclusion criteria were ability to understand and speak the main local language and age 18 years or older. The DISC-12 subscores assessed were reported discrimination and anticipated discrimination. Multivariable regression was used to analyse the data. FINDINGS 1082 people with depression completed the DISC-12. Of these, 855 (79%) reported experiencing discrimination in at least one life domain. 405 (37%) participants had stopped themselves from initiating a close personal relationship, 271 (25%) from applying for work, and 218 (20%) from applying for education or training. We noted that higher levels of experienced discrimination were associated with several lifetime depressive episodes (negative binomial regression coefficient 0·20 [95% CI 0·09-0·32], p=0·001); at least one lifetime psychiatric hospital admission (0·29 [0·15-0·42], p=0·001); poorer levels of social functioning (widowed, separated, or divorced 0·10 [0·01-0·19], p=0·032; unpaid employed 0·34 [0·09-0·60], p=0·007; looking for a job 0·26 [0·09-0·43], p=0·002; and unemployed 0·22 [0·03-0·41], p=0·022). Experienced discrimination was also associated with lower willingness to disclose a diagnosis of depression (mean discrimination score 4·18 [SD 3·68] for concealing depression vs 2·25 [2·65] for disclosing depression; p<0·0001). Anticipated discrimination is not necessarily associated with experienced discrimination because 147 (47%) of 316 participants who anticipated discrimination in finding or keeping a job and 160 (45%) of 353 in their intimate relationships had not experienced discrimination. INTERPRETATION Discrimination related to depression acts as a barrier to social participation and successful vocational integration. Non-disclosure of depression is itself a further barrier to seeking help and to receiving effective treatment. This finding suggests that new and sustained approaches are needed to prevent stigmatisation of people with depression and reduce the effects of stigma when it is already established. FUNDING European Commission, Directorate General for Health and Consumers, Public Health Executive Agency.

Feasibility and Effectiveness of a Multi-Element Psychosocial Intervention for First-Episode Psychosis: Results From the Cluster-Randomized Controlled GET UP PIANO Trial in a Catchment Area of 10 Million Inhabitants

Integrated multi-element psychosocial interventions have been suggested to improve the outcomes of first-episode psychosis (FEP) patients, but they have been studied primarily in experimental settings and in nonepidemiologically representative samples. Thus, we performed a cluster-randomized controlled trial, comparing an integrated multi-element psychosocial intervention, comprising cognitive behavioral therapy, family intervention, and case management, with treatment as usual (TAU) for FEP patients in 117 community mental health centers (CMHCs) in a large area of northern Italy (10 million inhabitants). The randomized units (clusters) were the CMHCs, and the units of observation the patients (and, when available, their family members). The primary hypotheses were that add-on multicomponent intervention: (1) results in greater improvements in symptoms, as assessed with positive and negative syndrome scale and (2) reduces in-hospital stay, based on days of hospitalization over the 9-month follow-up. Four hundred and forty-four FEP patients received the intervention or TAU and were assessed at baseline and 9 months. Based on the retention rates of patients (and families) in the experimental arm, multi-element psychosocial interventions can be implemented in routine mental health services. Regarding primary outcomes, patients in the experimental arm showed greater reductions in overall symptom severity, while no difference could be found for days of hospitalization. Among the secondary outcomes, greater improvements were detected in the experimental arm for global functioning, emotional well-being, and subjective burden of delusions. No difference could be found for service disengagement and subjective burden of auditory hallucinations. These findings support feasibility and effectiveness of early interventions for psychosis in generalist mental health services.

Social capital and reported discrimination among people with depression in 15 European countries

PurposeSocial capital is a protective factor for mental health. People with depression are vulnerable to discrimination and its damaging impact. No previous studies have explored the link between social capital and experienced or anticipated discrimination in people with depression. This study aims to test the hypothesis that levels of self-reported discrimination in people with depression are inversely associated with social capital levels.MethodA total of 434 people with major depression recruited in outpatient settings across 15 European countries participated in the study. Multivariable regression was used to analyse relationships between discrimination and interpersonal and institutional trust, social support and social network.ResultsSignificant inverse association was found between discrimination and social capital in people with major depression. Specifically, people with higher levels of social capital were less likely to have elevated or substantially elevated levels of experienced discrimination.ConclusionsHigher level of social capital may be closely associated with lower level of experienced discrimination among patients with major depression. It is important to explore these associations more deeply and to establish possible directions of causality in order to identify interventions that may promote social capital and reduce discrimination. This may permit greater integration in society and more access to important life opportunities for people with depression.

Self-stigma as a mediator between social capital and empowerment among people with major depressive disorder in Europe: the ASPEN study

INTRODUCTION Individual social capital has been recognized as having an important role for health and well-being. We tested the hypothesis that poor social capital increases internalized stigma and, in turn, can reduce empowerment among people with major depressive disorder (MDD). MATERIALS AND METHODS This is a cross-sectional multisite study conducted on a sample of 516 people with MDD in 19 European countries. Structural Equation Models were developed to examine the direct and indirect effects of self-stigma and social capital on empowerment. RESULTS Social capital and self-stigma accounted for 56% of the variability in empowerment. Higher social capital was related to lower self-stigma (r=-0.72, P<0.001) which, in turn, partially mediated the relationship between social capital and empowerment (r=0.38, P<0.001). CONCLUSIONS Social capital plays a key role in the appraisal of empowerment, both directly and through the indirect effect mediated by self-stigma. In order to improve empowerment of people with MDD, we identify strategies to foster individual social capital, and to overcome the negative consequences related to self-stigma for attainment of life goals.

Depression prevention and mental health promotion interventions : is stigma taken into account? An overview of the Italian initiatives

Depressive disorders represent a major public health concern in European countries and Italian epidemiological studies confirm that despite being highly prevalent in the general population and in clinical settings, their recognition and treatment are often inadequate (Balestrieri et al. 2004). Research suggested that the public stigma of mental disorders (defined as the general publics negative attitudes towards individuals with mental disorders) increases self-stigma (e.g. internalized attitudes held by people suffering from a mental disorder) with the consequences that individuals avoid seeking treatment and increase their social isolation (Kanter et al. 2008). In a survey on the Australian general population (Griffiths et al. 2008), personal stigma was associated with greater current psychological distress and lower depression literacy.

Anti stigma campaigns: really useful and effective? A critical review of the anti-stigma initiatives conducted in Italy

AIM Stigma related to mental illness determines important negative consequences to psychiatric patients. It is important to determine if the number of anti-stigma campaigns are effective and useful. This paper aims to identify anti-stigma projects carried out in Italy in the last ten years and to evaluate their effectiveness. METHOD Anti-stigma campaigns conducted in Italy in the last decade have been scrutinized. These campaigns have been identified through direct contact with promoting organizations, by a web search and by a search conducted on electronic scientific databases (PsycINFO, Medline and Embase). Anti-stigma campaigns thus identified have been classified according to a series of key methodological criteria proposed by the international literature. RESULTS 71 anti-stigma programs have been identified. These projects are significantly heterogeneous in both their conception and practical realization. A lack of information on the results obtained by the vast majority of the anti-stigma programs was found, thus not allowing to gain any insight on their effectiveness. Most of the reviewed programs did not follow procedures based on scientific evidence. DISCUSSIONS Anti-stigma programs should be founded on rigorous methodological principles and on the best evidence available; this is needed in order to create efforts with the highest rate of possible success.