Experiences of stigma and discrimination of people with schizophrenia in India

A qualitative enquiry on the impact of mental illness stigma on caregiving role and experiences in Singapore

Introduction

Given that mental illness stigma is a common occurrence amongst people with mental illness and caregivers (CGs) can be a potential victim of stigma themselves, there is a need to examine caregivers' perspective on the phenomenon. This study is part of a larger study which aims to qualitatively examine the concept of mental illness stigma amongst different stakeholders in Singapore.

Methods

Focus group discussions (FGDs) were conducted amongst 21 informal caregivers to explore the experience of stigma encountered by them and their care recipients, and how it may implicate their caregiving experience. Both inductive and deductive thematic analyses were employed to analyze the data.

Results

Three overarching themes of stigma encounters that may have implication on caregiving experience were identified: 1) Stigma within the family; 2) Structural stigma; and 3) Stigma by association. Experience of stigma within family (e.g., social exclusion and lack of understanding) limits the caregiving supports available to CGs. CGs also took up a mediating role between their care recipients and other family who may hold stigmatizing views. Witnessing their care recipients being subjected to structural disadvantages (e.g., employment, school, and mandatory conscription) can induce emotional stresses amongst CGs and motivate them to protest and seek redress on their behalf. Furthermore, encounters of stigma themselves (e.g., being judged or blamed for their loved one's condition) also led to feelings of guilt and self-blame amongst the CGs.

Discussion

These findings can aid the formulation of interventions in informing CGs on what to expect on their caregiving journey and supporting them in dealing with issues relating to stigma and highlight the importance of anti-stigma efforts in organizational settings such as schools, corporations, and government agencies.

Interventions to decrease health students' stigma toward schizophrenia: A scoping review

BACKGROUND

Schizophrenia is heavily stigmatized among health professionals. Given that health professional students are future members of the workforce and will provide care for people with schizophrenia, it is essential to implement interventions aimed at reducing stigma among this group.

OBJECTIVE

This scoping review aimed to identify and synthesize existing literature on interventions to decrease schizophrenia stigma among health professional students, and to determine the possible gaps in the literature.

DESIGN

Nine electronic databases and gray literature were searched, including PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, MEDLINE, Web of Science, Scopus, China National Knowledge Infrastructure, WanFang, and Google on 5 May 2023. Two researchers independently conducted data screening, data extraction, and assessed study risks. A most updated search was also done on 22 May 2024. The Cochrane risk of bias tool version 2 for randomized trials and Risk of Bias in Non-randomized Studies were used to assess the studies' risk of bias. Data synthesis and analysis were conducted by two reviewers using a narrative approach. Reporting adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews.

RESULTS

This review included twenty-one studies with 2520 health professional students. The majority of included studies were non-randomized controlled trials (38 %) and pre-post studies (52 %). Most of the included studies were conducted in the United States (24 %). The participants in ten (48 %) studies were medical students. The number of intervention sessions ranged from one to 13, with an average of three. Seven (33 %) studies had an intervention duration of less than four weeks and 16 (76 %) studies had no follow-up. Various scales were used to assess the outcomes of schizophrenia stigma. Only two studies (10 %) indicated the intervention's ineffectiveness, with the majority of interventions led by psychiatry department faculty and individuals with schizophrenia.

CONCLUSIONS

Most studies (90 %) utilized various approaches, including face-to-face or online education, direct contact with individuals with schizophrenia, or a combination thereof, to diminish stigma among health professional students. However, none addressed cultural and empathy factors in their intervention designs, and the included studies lacked theoretical guidance. The review only comprised English quantitative studies with significant heterogeneity, with 17 studies (81 %) displaying serious or high risk of bias, limiting comprehensive discussions. These findings offer valuable insights for future systematic review. Tweetable abstract Studies on reducing health professional students' schizophrenia stigma need to address cultural and empathy factors.

A Systematic Review of the Effect of Stigmatization on Psychiatric Illness Outcomes

A significant proportion of individuals with psychiatric disorders face dual challenges such as managing the symptoms and disabilities of their conditions and enduring stigma arising from misconceptions about mental illness. This stigma denies them quality-of-life opportunities, such as access to satisfactory healthcare services, better employment, safer housing, and social affiliations. This systematic review aims to evaluate the effect of stigmatization on psychiatric illness outcomes, particularly its influence on treatment adherence, treatment-seeking behavior, and care outcomes. We conducted a systematic review of 39 studies published between 2010 and 2024, focusing on the effects of stigmatization on psychiatric illness outcomes. The review utilized robust methodology following Cochrane guidance and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including studies from 2010 to 2024 obtained from databases such as PubMed, Embase, Google Scholar, Web of Science, and SCOPUS. The quality of the included studies was assessed using the Appraisal Tool for Cross-Sectional Studies, with most studies rated as moderate to high quality. The findings indicate that stigma in psychiatric illness is closely associated with several factors, including illness duration (mean effect size = 0.42, p < 0.05), frequency of clinic visits (mean reduction = 2.3 visits/year), and diagnosis of psychotic disorders (OR = 1.78, 95% CI: 1.20-2.65). Stigma manifests through misinformation, prejudice, and discrimination, leading to significant barriers to accessing and adhering to psychiatric treatment, thereby worsening health outcomes. It leads to delays in accessing healthcare, poor adherence to medication and follow-up, and negative psychiatric health outcomes, including disempowerment, reduced self-efficacy, increased psychiatric symptoms, and decreased quality of life. Also, stigma extends to caregivers and healthcare professionals, complicating care delivery. This review highlights the need for effective interventions and strategies to address stigma, emphasizing the importance of educational interventions to mitigate the adverse effects of public stigma. Understanding the multifaceted nature of stigma is crucial for developing targeted approaches to improve psychiatric care outcomes and ensure better mental health services for individuals with mental illnesses.

Systematic review and meta-analysis of internalised stigma and stigma resistance in patients with psychosis: The impact of individualism-collectivism culture and other individual factors

PURPOSE

This study aimed to meta-analysis the level of internalised stigma experienced by individuals with psychosis worldwide, and the impact of cultural differences, economic status of the studied regions and duration of illness on their levels of internalised stigma. Clinical and individual level factors associated with internalised stigma and stigma resistance were also systematically reviewed.

METHODS

A systematic search of keywords on two scholarly databases were conducted. The individualism index of the countries or regions where the studies were conducted was retrieved from Hofstede's updated measurement of individualism. Economic status of regions was categorised based on their per capita gross national income. Meta-analysis and meta-regression were conducted using the 'metafor' package in R. Factors associated with internalised stigma and stigma resistance were also systematically consolidated.

RESULTS

Seventy-three articles were included in the meta-analysis and the pooled score of both internalised stigma and stigma resistance of individuals with psychosis were within the mild range (2.20 and 2.44, respectively). The meta-regression analysis found high collectivism culture is significantly related to a higher level of internalised stigma. Economic status was not significant. Thirty-five articles were included in the systematic review and clinical, psychological, psychosocial variables, cognition and sociodemographic factors were found to be associated with internalised stigma.

CONCLUSION

Internalised stigma in psychosis is ubiquitous worldwide and high collectivism culture may be related with high internalised stigma. With the presence of multiple individual factors related to internalised stigma, intervention programmes to reduce internalised stigma should consider focussing on both macro- and micro-level factors.

Collaborative care approaches for people with severe mental illness

BACKGROUND

Collaborative care for severe mental illness (SMI) is a community-based intervention that promotes interdisciplinary working across primary and secondary care. Collaborative care interventions aim to improve the physical and/or mental health care of individuals with SMI. This is an update of a 2013 Cochrane review, based on new searches of the literature, which includes an additional seven studies.

OBJECTIVES

To assess the effectiveness of collaborative care approaches in comparison with standard care (or other non-collaborative care interventions) for people with diagnoses of SMI who are living in the community.

SEARCH METHODS

We searched the Cochrane Schizophrenia Study-Based Register of Trials (10 February 2021). We searched the Cochrane Common Mental Disorders (CCMD) controlled trials register (all available years to 6 June 2016). Subsequent searches on Ovid MEDLINE, Embase and PsycINFO together with the Cochrane Central Register of Controlled Trials (with an overlap) were run on 17 December 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) where interventions described as 'collaborative care' were compared with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI. SMI was defined as schizophrenia, other types of schizophrenia-like psychosis or bipolar affective disorder. The primary outcomes of interest were: quality of life, mental state and psychiatric admissions at 12 months follow-up.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently extracted data. We assessed the quality and certainty of the evidence using RoB 2 (for the primary outcomes) and GRADE. We compared treatment effects between collaborative care and standard care. We divided outcomes into short-term (up to six months), medium-term (seven to 12 months) and long-term (over 12 months). For dichotomous data we calculated the risk ratio (RR) and for continuous data we calculated the standardised mean difference (SMD), with 95% confidence intervals (CIs). We used random-effects meta-analyses due to substantial levels of heterogeneity across trials. We created a summary of findings table using GRADEpro.

MAIN RESULTS

Eight RCTs (1165 participants) are included in this review. Two met the criteria for type A collaborative care (intervention comprised of the four core components). The remaining six met the criteria for type B (described as collaborative care by the trialists, but not comprised of the four core components). The composition and purpose of the interventions varied across studies. For most outcomes there was low- or very low-certainty evidence. We found three studies that assessed the quality of life of participants at 12 months. Quality of life was measured using the SF-12 and the WHOQOL-BREF and the mean endpoint mental health component scores were reported at 12 months. Very low-certainty evidence did not show a difference in quality of life (mental health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.03, 95% CI -0.26 to 0.32; 3 RCTs, 227 participants). Very low-certainty evidence did not show a difference in quality of life (physical health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.08, 95% CI -0.18 to 0.33; 3 RCTs, 237 participants). Furthermore, in the medium term (at 12 months) low-certainty evidence did not show a difference between collaborative care and standard care in mental state (binary) (RR 0.99, 95% CI 0.77 to 1.28; 1 RCT, 253 participants) or in the risk of being admitted to a psychiatric hospital at 12 months (RR 5.15, 95% CI 0.67 to 39.57; 1 RCT, 253 participants). One study indicated an improvement in disability (proxy for social functioning) at 12 months in the collaborative care arm compared to usual care (RR 1.38, 95% CI 0.97 to 1.95; 1 RCT, 253 participants); we deemed this low-certainty evidence. Personal recovery and satisfaction/experience of care outcomes were not reported in any of the included studies. The data from one study indicated that the collaborative care treatment was more expensive than standard care (mean difference (MD) international dollars (Int$) 493.00, 95% CI 345.41 to 640.59) in the short term. Another study found the collaborative care intervention to be slightly less expensive at three years.

AUTHORS' CONCLUSIONS

This review does not provide evidence to indicate that collaborative care is more effective than standard care in the medium term (at 12 months) in relation to our primary outcomes (quality of life, mental state and psychiatric admissions). The evidence would be improved by better reporting, higher-quality RCTs and the assessment of underlying mechanisms of collaborative care. We advise caution in utilising the information in this review to assess the effectiveness of collaborative care.

Integrating Subjective Recovery and Stigma Resistance in Individuals with Schizophrenia: A Narrative Review and Theoretical Integration

Stigmatised attitudes are known to be associated with negative outcomes in schizophrenia, yet there is little focus on the role of stigma in the recovery process. Attempts to develop interventions to reduce self-stigma in schizophrenia have not been found effective. This paper presents a theoretical integration based on a narrative review of the literature. PsycINFO, Medline and Embase databases were searched up to the 11th December 2023. Studies were included if they were: i) empirical studies using qualitative, quantitative or mixed methods studies investigating mental health stigma; ii) included participants based in the United Kingdom, fluent in English, between the ages of 16 and 70, meeting criteria for a schizophrenia spectrum diagnosis. Fourteen studies were included. In Part 1, we propose a novel theoretical model derived from a synthesis of service-user perspectives on the relationship between stigma and schizophrenia. Stigmatised attitudes were commonly perceived to be caused by a lack of education and further exacerbated by disinformation primarily through the media and cultural communities. Stigma led to negative self-perceptions, negative emotional responses, social isolation and increased symptom severity, ultimately acting as a barrier to recovery. In Part 2, we identify several factors that ameliorate the impact of stigma and promote clinical and subjective recovery among service-users: education, empowerment, self-efficacy, self-acceptance, hope and social support. We argue that the notion of stigma resistance may be helpful in developing new interventions aimed at promoting recovery in individuals with schizophrenia. Wider implications are discussed and recommendations for future research and practice are explored.

Honest, Open, Proud (HOP) for people with mental illness in Hong Kong: a randomized controlled trial

BACKGROUND

Self-stigma among people with mental illness is negatively associated with personal and clinical recovery. Due to the concealable nature of mental illness, people with mental illness experience constant struggles between concealment and disclosure. Disclosure of mental health challenges can potentially minimize negative impacts of self-stigma and enhance self-esteem and sense of empowerment. Honest, Open, Proud (HOP) is a peer-led intervention that promotes autonomous and dignified decisions about disclosure.

PURPOSE

This study examined the effectiveness of HOP on concealment motivation, empowerment, self-stigma, stigma stress, and recovery among people with lived experience of mental illness in Hong Kong.

METHODOLOGY

A total of 162 participants with a mean age of 45.38 were recruited and randomized into intervention group and waitlist control group. Participants in the intervention group were invited to attend a 6-session HOP group intervention.

RESULTS

Significant improvement in optimism score from the empowerment scale was found in the intervention group compared to the waitlist control group and the effect was sustained at 1-month follow-up. However, significant changes were not found in other outcome variables.

CONCLUSION

Only improvement in optimism was observed in the current study. Future study needs to examine the effects of HOP with further modification to maximize the benefit for people with lived experience of mental illness in the local context.

Social Stigma Toward Individuals with Schizophrenia in a Lebanese Population

Background

Schizophrenia has been recognized as the most stigmatized mental disorder, imposing a substantial burden on affected individuals. However, no prior studies have investigated social stigma toward individuals with schizophrenia in Lebanon.

Purpose

We aimed to examine three components of social stigma including knowledge, attitude, and behavior toward individuals with schizophrenia in a Lebanese population and to explore associated factors with the level of social stigma.

Patients and Methods

A cross-sectional online survey was administered, and data from 469 participants were gathered from January 31, 2023, to February 18, 2023. We used previously validated questionnaires to assess the knowledge, attitude (Social Distance Scale), and behavior (Reported and Intended Behavior Scale) of participants toward individuals with schizophrenia. The score for each section was calculated and used to explore the associations between sociodemographic factors and the levels of stigma in each domain.

Results

The study participants had a moderate understanding of schizophrenia. However, a substantial proportion showed negative attitudes and unfavorable behaviors toward individuals with schizophrenia. We identified several sociodemographic factors associated with the knowledge, attitude, and behavior scores. Notably, a higher knowledge score and more positive attitudes were positively correlated with improved intended behaviors.

Conclusion

This study highlights the pervasive stigma encompassing issues in knowledge, attitudes, and behavior surrounding schizophrenia in a Lebanese population. Our study suggests a pressing need for targeted interventions to increase public awareness and decrease the social stigma of schizophrenia in Lebanon.

Dyadic effects of stigma on quality of life in people with schizophrenia and their family caregivers: Mediating role of patients' perception of caregivers' expressed emotion

Schizophrenia, as a stressful diagnosis, profoundly impacts the whole family, especially people with schizophrenia and their caregivers. This study tested the potential mediating role of expressed emotion in the association between mental health stigma and quality of life in caregiver-patient dyads. Using a 2-wave longitudinal design with a 6-month interval between assessments, 161 dyads of patients with schizophrenia and their family caregivers (one patient and one caregiver) completed measures of mental health stigma, expressed emotion, and quality of life. The results showed that patients' self-stigma had no significant actor or partner effect on expressed emotion or quality of life. In contrast, caregivers' stigmatizing attitudes toward patients had a significant partner effect on patients' perception of caregivers' expressed emotion and quality of life. The mediating effect of patients' perception of caregivers' expressed emotion in the association between caregivers' stigmatizing ideas toward patients and patients' quality of life was significant. By focusing on the interdependence of patients and their caregivers, this study highlights the role of caregivers' stigmatizing attitudes toward patients and patients' perception of caregivers' expressed emotion on patients' quality of life. Psychoeducation and interventions should not only aim to reduce the self-stigma of people with schizophrenia but also their caregivers' stigmatizing ideas toward patients. Family interventions targeted at reducing the EE level of caregivers and patients' perception of caregivers' EE would also benefit the adaptation and quality of life of people with schizophrenia and their caregivers.

People with mental illness stigmatize mental illness less: A comparison study between a hospital-based sample of people with mental illness and a non-clinical general population sample in urban India

Evidence shows that stigma negatively influences the quality of life of persons with severe mental illness. Nonetheless, stigma towards mental illness is lower among persons with a lived experience of mental illness compared to the rest of the population. Understanding the association between stigma of mental illness and the mental status of individuals living in urban India and whether this association is moderated by demographic factors opens a new avenue for prevention of social exclusion. Persons diagnosed with schizophrenia, bipolar disorder, or severe unipolar depression (cases, n  =  647) were recruited from among hospital patients in New Delhi between November 2011 and June 2012 and matched with non-psychiatric urban dwellers by age, sex, and location of residence (controls, n  =  649). Propensity score matching with multivariable linear regression was used to test whether stigma towards mental illness, measured by a 13-item Stigma Questionnaire, differed between cases and controls. Cases reported significantly lower stigma scores than controls (b  =  -0.50, p < 0.0001). The strength of the association between mental illness and stigma was not affected after controlling for age, caste, sex, education, and employment status, while wealth marginally reduced the strength of the association. These findings suggest individuals with a lived experience of mental illness, in New Delhi, India, may be more tolerant towards mental illness and support the need to involve persons with lived experience in the development and implementation of health promotional campaigns and programs aimed at reducing stigma towards mental illness.

Discrimination reported by people with schizophrenia: cross-national variations in relation to the Human Development Index

AIMS

Mental health related stigma and discrimination is a universal phenomenon and a contributor to the adversity experienced by people with schizophrenia. Research has produced inconsistent findings on how discrimination differs across settings and the contextual factors that underpin these differences. This study investigates the association between country-level Human Development Index (HDI) and experienced and anticipated discrimination reported by people with schizophrenia.

METHODS

This study is a secondary data analysis of a global cross-sectional survey completed by people living with schizophrenia across 29 countries, between 2005 and 2008. Experienced and anticipated discrimination were assessed using the Discrimination and Stigma Scale (DISC-10). Countries were classified according to their 2006 HDI. Negative binomial and Poisson regression analyses with a robust standard errors approach were conducted to investigate associations between country-level HDI and discrimination.

RESULTS

In the regression analyses, no evidence was found for a linear association between HDI and experienced or anticipated discrimination. Further exploratory analyses showed a significant non-linear association between HDI ratings and experienced discrimination. Participants in "high" and "very high" HDI countries reported more experienced discrimination compared to those in "medium" HDI countries.

CONCLUSIONS

HDI does, to some extent, appear to be associated with how far discrimination is experienced across different contexts. More high-quality cross-national research, including research focused on "medium" and "low" countries, is needed to substantiate these findings and identify underlying factors that may explain the pattern observed for experienced discrimination, including generating new datasets that would enable for these analyses to be repeated and contrasted with more recent data. An in-depth understanding of these factors will further aid the adaptation of cross-cultural and context specific anti-stigma interventions in future.

COPSYC-19: The impact of early phase lockdown on mental health among people with psychotic disorders

PURPOSE

On March 12th 2020 extensive measures were implemented to prevent spread of the coronavirus disease-19 (COVID-19). These measures were commonly referred to as "lockdown". In this study we investigate the psychological impact associated with living under these circumstances among patients with psychotic disorders receiving care from specialized mental health services in Norway.

METHOD

During early phases of lockdown, patients and clinicians receiving and providing mental health care for psychotic disorders in specialized health services at Oslo University Hospital were asked to fill out questionnaires developed for the study. 129 participants from outpatient clinics (91 patients and 38 clinicians) and 89 from inpatient wards (15 patients and 74 clinicians) were recruited. Data regarding mental health and related symptoms were analysed using Wilcoxon signed rank tests and standard multiple regression.

RESULTS

Outpatients reported significantly less extensive worrying, loneliness and hallucinatory experiences during early phase lockdown compared to the two weeks prior. Reductions in loneliness were predictive of experienced improvement in subjective mental health. However, the majority of clinicians from outpatient clinics believed their patients were experiencing more worrying and loneliness.

CONCLUSION

The result of this study suggests that many patients with psychosis experienced less loneliness, excessive worrying and hallucinations during the first phase of lockdown. This contrasts the clinicians' perceptions, as the patients show signs of resilience during times of uncertainty. The limitation in the study timeframe should be noted.

Family caregivers' abusive behaviour and its association with internalized stigma of people living with schizophrenia in China

Family caregiving of people living with schizophrenia (PLS) can be burdensome, and some family caregivers may perpetrate abusive behavior that could be harmful to PLS. This study aims to examine the association of family caregivers' abusive behavior with internalized stigma of PLS and draw attention to this problem. PLS were recruited from four cities across China and completed measures of abusive behavior and internalized stigma. Linear regression analyses were used to determine the association between family caregivers' abusive behavior and internalized stigma of PLS. A total of 693 PLS were include in this study. 22.7% of the participants had experienced one or more of the abusive behaviors perpetrated by family caregivers. The most common type of abusive behavior towards PLS was verbal abuse and 4.2% of the participants reported physical abuse. 44.6 % of participants reported a high level of internalized stigma. PLS who experienced any abusive behavior by family caregivers had significantly higher levels of internalized stigma. Family caregivers' abusive behavior is positively associated with alienation and social withdrawal but not with stereotype endorsement and discrimination of PLS. To end all forms of stigma and discrimination against PLS, more attention needs to be paid to the families of PLS.

Effectiveness of Community-Based Rehabilitation Interventions on Symptoms and Functioning for People with Schizophrenia: A Systematic Review and Meta-Analysis

Schizophrenia is a serious mental illness that imposes huge burden of illness on the society. We aimed to conduct a meta-analytic and systematic review of literature on the effectiveness of community-based rehabilitation interventions on symptoms and functioning for people with schizophrenia. The PubMed, Embase, the Cochrane Library, Web of Science, and CINAHL databases were searched through April 16 and 17, 2021, including clinical trial registries and previous Cochrane reviews. We included 24 randomized controlled trials in this review. The content of interventions varied from single-faceted rehabilitation intervention or cognitive retraining, to multi-component rehabilitation interventions or case management. Among 20 studies that reported effects of community-based rehabilitation interventions on symptoms, the pooled SMDs across all interventions was 0.94 (95% CI = 0.11, 1.76; P < 0.001; I2 = 99.1%; n = 3694), representing a strong effect. 21 included studies showed that community-based rehabilitation interventions also had beneficial impacts on functioning (SMD = 1.65; 95% CI = 0.88, 2.43; P < 0.001; I2 = 98.9%; n = 3734). Overall quality of evidence was moderate with a high level of heterogeneity. Community-based rehabilitation interventions have positive effectiveness in improving patients' symptoms and functioning. Community-based rehabilitation interventions should therefore be provided as an adjuvant service in addition to facility-based care for people with schizophrenia.

Improving mental ill-health with psycho-social group interventions in South Asia-A scoping review using a realist lens

This scoping review aimed to synthesise current evidence related to psycho-social groups as part of community-based mental health interventions in South Asia. We used a realist lens to pay attention to the contexts and mechanisms supporting positive outcomes. We included studies published from January 2007 to February 2022 that: were based in communities in South Asia, included a group component, reported on interventions with a clear psychosocial component, targeted adults and were implemented by lay community health workers. Two reviewers extracted data on intervention components, groups and facilitators, participant demographics and enabling contexts, mechanisms and outcomes. Expert reference panels including people with lived experience of psycho-social disability, mental health professionals and policy makers confirmed the validity and relevance of initial review findings. The review examined 15 interventions represented by 42 papers. Only four interventions were solely psycho-social and nearly all included psychoeducation and economic support. Only 8 of the 46 quantitative outcome measures used were developed in South Asia. In a context of social exclusion and limited autonomy for people with psychosocial disability, psychosocial support groups triggered five key mechanisms. Trusted relationships undergirded all mechanisms, and provided a sense of inclusion, social support and of being able to manage mental distress due to improved skills and knowledge. Over time group members felt a sense of belonging and collective strength meaning they were better able to advocate for their own well-being and address upstream social health determinants. This led to outcomes of improved mental health and social participation across the realms of intrapersonal, interpersonal and community. Psychosocial groups merit greater attention as an active ingredient in community interventions and also as an effective, relevant, acceptable and scalable platform that can promote and increase mental health in communities, through facilitation by lay community health workers.

A qualitative of stable symptomatology for patients with schizophrenia: do they have adequate post-discharge rehabilitative resources?

Many patients diagnosed with schizophrenia face obstacles to rehabilitation and discharge into the community, particularly with regard to the way resources are structured. Clarifying the difficulties will help health care providers address rehabilitation shortcomings. Semistructured in-depth interviews and participatory observations were conducted in various locations (family home, hospital ward, outpatient clinic, and on the street) with families, social workers, doctors, nursing staff, and patients with schizophrenia. These patients met the medical facility's hospital discharge standards and either had not been discharged or had been discharged within two weeks of meeting the discharge criteria. This study explores the complex and interdependent role of social differences in the rehabilitation of patients with schizophrenia after acute treatment. The study identified five topics related to structural difficulties in resources for the rehabilitation of patients diagnosed with schizophrenia: (1) the role of policy; (2) inadequate facilities and responsibilities; (3) rejecting communities; (4) difficult families; and (5) the threat of stigma. The rehabilitation of patients diagnosed with schizophrenia is a systemic problem. Systemic rehabilitation policies and integrated social support would be more conducive to the rehabilitation of patients. Perhaps cognitive remediation therapy or the Assertive Community Treatment (ACT) Model could benefit individuals with complex disorders.

Mental health related stigma, service provision and utilization in Northern India: situational analysis

Stigma, discrimination, poor help seeking, dearth of mental health professionals, inadequate services and facilities all adversely impact the mental health treatment gap. Service utilization by the community is influenced by cultural beliefs and literacy levels. We conducted a situational analysis in light of the little information available on mental health related stigma, service provision and utilization in Haryana, a state in Northern India. This involved: (a) qualitative key informant interviews; (b) health facility records review; and (c) policy document review to understand the local context of Faridabad district in Northern India. Ethical approvals for the study were taken before the study commenced. Phone call in-depth interviews were carried out with a purposive sample of 13 participants (Mean = 38.07 years) during the COVID-19 pandemic, which included 4 community health workers, 4 people with mental illness, 5 service providers (primary health care doctors and mental health specialists). Data for health facility review was collected from local primary health and specialist facilities while key policy documents were critically analysed for service provision and stigma alleviation activities. Thematic analysis was used to analyse patterns within the interview data. We found poor awareness and knowledge about mental illnesses, belief in faith and traditional healers, scarcity of resources (medicines, trained professionals and mental health inpatient and outpatient clinics), poor access to appropriate mental health facilities, and high costs for seeking mental health care. There is a critical gap between mental health related provisions in policy documents and its implementation at primary and district level.

The experience of stigma in family caregivers of people with schizophrenia spectrum disorders: A meta-synthesis study

Introduction

Schizophrenia is a chronic disabling and the most stigmatizing mental disorder worldwide. The stigma experienced by family caregivers impacts their lives in different ways. This study reports the results of qualitative synthesis to understand the perceptions and experiences of stigma in families of people with schizophrenia spectrum disorders across various socio-cultural contexts.

Methods

An initial comprehensive search was performed in databases like Web of Science, PsycINFO, CINAHL, Scopus, and Ovid-based MEDLINE. By searching, 3560 studies were found, of which 16 articles were included in the present study. A meta-synthesis was done according to the meta-ethnographic approach.

Result

Three themes were generated: perpetuated stigma by general misunderstandings about schizophrenia, mental health inequality contributes to structural stigma, and long-term family caregiving stigmas, attitudes, and coping strategies. These themes indicated the essential experiences of stigma in families of people with schizophrenia, which appeared due to unknown and socio-cultural misconceptions of schizophrenia that led to emotional challenges for family caregivers.

Conclusion

This study addresses stigma-related issues, and coping strategies used almost exclusively by family caregivers. Health policymakers and healthcare professionals working in mental health institutions should consider this data. Substantial steps must be taken to combat stigma, with education initiatives topping the list.

Mixed-Method Investigations Uncovering Tension, PTSD Symptoms, and Trauma-Related Difficulties Among Indian Women from Slums Reporting Gender-Based Violence

Indian women exposed to gender-based violence (GBV) report experiencing cultural concepts of distress, such as tension, and trauma-related difficulties. However, tension and trauma-related sequalae have not been explicitly explored. The present study examined the symptoms, causes, and coping strategies associated with tension among slum-residing Indian women reporting GBV (N = 100). This study also explored linkages between tension and posttraumatic stress disorder (PTSD) symptom severity. Qualitative results among a subsample of women (n = 38) indicated tension was commonly reported. Tension was characterized by varied affective, behavioral, cognitive, and somatic components and was most commonly caused by interpersonal stressors. Participants described various coping strategies to manage tension, including avoiding, cognitively reframing, considering consequences, distracting themselves, seeking medical, religious and/or spiritual assistance, finding social support, and tolerating tension. Barriers to coping were stigma, hopelessness about present circumstances, and negative reactions from others. One-way analysis of covariance with Bonferroni-adjusted post hoc results (N = 100) indicated that participants with higher tension exhibited significantly higher PTSD symptom severity as compared to participants reporting no tension. Altogether, the polyvalence of tension suggested that it requires idiographic assessment. Tension appears responsive to skills consistent with evidence-based psychological treatments for Indian women from slums reporting GBV.

Stigma in people living with bipolar disorder and their families: a systematic review

BACKGROUND

Stigma affects different life aspects in people living with bipolar disorder and their families. This study aimed to examining the experience of stigma and evaluating predictors, consequences and strategies to combat stigma in people with bipolar disorder and their families.

METHODS

We conducted a systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) in 2022. We extensively reviewed six online databases (PubMed, Scopus, Medline, EMBASE, Web of Science and Google Scholar). Articles published in the English language about stigma in people living with bipolar disorders and their families were included.

RESULTS

A total of 42,763 articles were retrieved, of which 40 articles from 14 countries were included in this study (n = 7417 participants). Of the 40 articles, 29 adopted quantitative methods (72.5%), two used mixed-methods (5%), eight used qualitative (20%) methods, and one was a case series (2.5%). The results of the studies were categorized into four themes: 1. Stigma experienced by people living with bipolar disorders and their families, 2. Predictors of stigma in people living with bipolar disorders and their families, 3. Consequences of stigma in people living with bipolar disorders and their families, 4. Effective interventions and strategies to reduce stigma in people living with bipolar disorders and their families.

CONCLUSION

The results of this study might be useful to design psychiatric cognitive interventions to reduce stigma in people living with bipolar disorders and their families and designing community-based interventions to normalize bipolar disorder at the community level.

Toward a multi-level strategy to reduce stigma in global mental health: overview protocol of the Indigo Partnership to develop and test interventions in low- and middle-income countries

There is increasing attention to the impacts of stigma and discrimination related to mental health on quality of life and access to and quality of healthcare. Effective strategies for stigma reduction exist, but most evidence comes from high-income settings. Recent reviews of stigma research have identified gaps in the field, including limited cultural and contextual adaptation of interventions, a lack of contextual psychometric information on evaluation tools, and, most notably, a lack of multi-level strategies for stigma reduction. The Indigo Partnership research programme will address these knowledge gaps through a multi-country, multi-site collaboration for anti-stigma interventions in low- and middle-income countries (LMICs) (China, Ethiopia, India, Nepal, and Tunisia). The Indigo Partnership aims to: (1) carry out research to strengthen the understanding of mechanisms of stigma processes and reduce stigma and discrimination against people with mental health conditions in LMICs; and (2) establish a strong collaborative research consortium through the conduct of this programme. Specifically, the Indigo Partnership involves developing and pilot testing anti-stigma interventions at the community, primary care, and mental health specialist care levels, with a systematic approach to cultural and contextual adaptation across the sites. This work also involves transcultural translation and adaptation of stigma and discrimination measurement tools. The Indigo Partnership operates with the key principle of partnering with people with lived experience of mental health conditions for the development and implementation of the pilot interventions, as well as capacity building and cross-site learning to actively develop a more globally representative and equitable mental health research community. This work is envisioned to have a long-lasting impact, both in terms of the capacity building provided to participating institutions and researchers, and the foundation it provides for future research to extend the evidence base of what works to reduce and ultimately end stigma and discrimination in mental health.

Exploring the feasibility and public health impact of integrating a community-based recovery-oriented intervention for people living with schizophrenia in partnership with a tertiary care mental hospital in India

Background

There is a priority need to make community-based care widely available for people living with schizophrenia (PLwS) in low- and middle-income countries. An innovative approach for increasing access could be to integrate clinical services available in tertiary care hospitals with community-based care through a task-sharing approach. We describe such an integrated intervention that was implemented at Tezpur in northeast India in collaboration with the Lokopriya Gopinath Bordoloi Regional Institute of Mental Health (LGBRIMH).

Method

The objectives of the study were to illustrate the feasibility of integrating and implementing the intervention and to describe its individual, systemic, and public health impacts. Due to the limited resources available, we conducted a pragmatic single-arm longitudinal evaluation of the intervention cohort over 24 months.

Results

Of the 239 PLwS enrolled in the intervention, 198 (83%) were followed up for 24 months, with nearly three-quarters reporting a >70% reduction in disabilities, most notably between 6 and 18 months. There was a marked reduction in unmet needs across multiple domains, and at 24 months, 62% of the cohort was engaged in individual jobs or other market-linked livelihood opportunities. There was greater uptake and retention with outpatient contacts at the LGBRIMH, and PLwS experienced a marked (82%) reduction in inpatient admissions rates, as compared to before enrolment. Over a period of 24 months, primary caregivers reported that their families experienced significantly fewer social difficulties such as unemployment, interpersonal conflicts, and social isolation. The intervention had a significant public health impact, with an estimated 51.8% effective treatment coverage rate for the integrated intervention.

Conclusion

Our findings provide preliminary evidence of the feasibility of implementing the integrated intervention and its effectiveness. We believe that there is merit in further in-depth refinement and exploration of this implementation-related research and cost analysis while replicating the intervention in other tertiary care institutions.

The Effect of Psycho-education on the Affiliate Stigma in Family Caregivers of People with Bipolar Disorder

Introduction

Paying attention to stigma among caregivers to provide proper care for patients is necessary, and promoting awareness (about mental illness and mental health) to taking care of the caregivers' health, is crucial.

Objective

This study aimed to investigate the effect of psycho-education on the affiliate stigma in family caregivers of people with bipolar disorder.

Method

This study is a quasi-experimental research with an experimental and control groups. 64 family caregivers of people with bipolar disorder participated in this study (32 in each group). Data was collected using the demographic questionnaire and Affiliate Stigma Scale before and after intervention (with 4 weeks gap). The experimental group received a psycho-education program for four weeks. The control group carried on their normal routine lifestyle.

Results

The mean scores of the affiliate stigma of both control and experimental groups before the intervention did not show a statistically significant difference (P = .36), however after the intervention the results were statistically significant and increased in the experimental group (P < .001).

Conclusion

According to the findings of this study psycho-education is an effective intervention that can reduce the affiliate stigma among family caregivers of people with bipolar disorder and it can be considered as one of the de-stigmatization strategies for them.

Mental health effects of education

We analyze the role of education as a determinant of mental health. To do this, we leverage the age-specific exposure to an educational reform as an instrument for years of education and find that the treated cohorts gained more education. This increase in education had an effect on mental health more than 2 decades later. An extra year of education led to a lower likelihood of reporting any symptoms related to depression (11.3%) and anxiety (9.8%). More educated people also suffered less severe symptoms - depression (6.1%) and anxiety (5.6%). These protective effects are higher among women and rural residents. The effects of education on mental well-being that we document are potentially mediated through better physical health, improved health behavior and knowledge, and an increase in women's empowerment.

Perspectives of Nursing Students towards Schizophrenia Stigma: A Qualitative Study Protocol

Aim: This study aims to explore fourth-year nursing students’ knowledge of schizophrenia and their attitudes, empathy, and intentional behaviours towards people with schizophrenia. Design: This will be a descriptive qualitative study using focus-group interviews. Methods: Fourth-year nursing students on clinical placement in a hospital in Hunan province will be invited for focus-group interviews. Snowball and purposive sampling will be used to recruit nursing students for this study. Five focus-group interviews, each including six participants, will be conducted to explore participants’ knowledge, attitudes, intentional behaviours, and empathy towards schizophrenia. The interview will be conducted through the online Tencent video conference platform and the interview data will be collected through the same platform. All interviews will be recorded and transcribed verbatim and analysed with the approach of the content analysis supported by NVivo 12. Simultaneous data collection and analysis will be performed, and the interviews will be continued until data saturation is met. The findings of this study will be helpful in developing effective interventions to decrease the stigma toward schizophrenia among nursing students and those who study healthcare disciplines.

Anti-stigma psychosocial intervention effects on reducing mental illness self-stigma and increasing self-esteem among patients with schizophrenia in Taiwan: A quasi-experiment

Previous studies have noted that as self-stigma in patients with schizophrenia increases, their quality of life and self-esteem decrease. Considering the cultural differences and scarcity of self-stigma intervention research in Asia, the purpose of this study was to evaluate the intervention effects of the Against Stigma Program on reducing self-stigma and increasing self-esteem among patients with schizophrenia. In this study, 70 patients with schizophrenia were recruited from 3 community psychiatric rehabilitation institutions in Taiwan and assigned to the experimental and control groups. Controls received their usual treatment, and those in the experimental group participated in the Against Stigma Program (60-minute weekly sessions for 6 weeks). The participants were assessed at baseline, post-intervention, and 1-month follow-up, using the Internalized Stigma of Mental Illness Scale (ISMIS) and Rosenberg Self-Esteem Scale (RES). Generalized estimating equations (GEE) were used to analyze the changes in scores over time and differences between the experimental and control groups. Self-stigma significantly decreased and self-esteem significantly increased after participation in the Against Stigma Program. The GEE analysis revealed significant group and time interactions such that self-stigma reduction effect (B = -0.291) was stronger in the experimental group at post-intervention, and self-esteem promotion effects at post-intervention (B = 0.823) and 1-month follow-up (B = 0.543) were both greater in the experimental group. In conclusion, these findings suggest that the Against Stigma Program can help reduce self-stigma and increase self-esteem of patients with schizophrenia. This study can be used as an empirical reference to inform future clinical care of patients with schizophrenia in Taiwan.

The Hair in the Garland: Hair Loss and Social Stress Among Women in South India

Generations of scholars have debated hair's significance as a symbol of womanhood, fertility, and spiritual morality in South India. For contemporary Indian women, hair is a site of concern, often expressed as an everyday preoccupation with hair loss or "hair fall," as it is known in the subcontinent. This exploratory study investigated hair fall among Kannada-speaking Hindu women in the South Indian city of Mysuru, Karnataka. It used a series of focus group discussions to explore how women talk about the causes and consequences of hair fall, and how women cope with hair-related distress. Participants articulated clear, shared ideas about why hair falls and how it can be managed. They connected hair fall to broader stressors in their lives both directly and symbolically. Hair fall, therefore, appears to function idiomatically in this context, both as an idiom of distress in its own right, and as a symptom of other idioms and forms of distress. Additional research is needed to establish the importance of hair fall relative to other distress constructs, and to more directly assess its potential value in research and intervention.

Coping with personal care and stigma: experiences of persons living with schizophrenia

Living with a chronic mental condition such as schizophrenia impacts significantly on the individual’s social functioning and activities of daily living. However, there is little data on the experiences of people living with schizophrenia, especially in Ghana regarding personal care and stigma. This study explored qualitatively the experiences of people living with schizophrenia in Southern Ghana. Nine people with schizophrenia were purposively recruited for this study. Data were collected using semi-structured interviews and analysed thematically following a descriptive phenomenological data analysis framework. The study revealed that people with schizophrenia are capable of performing some activities of daily living, such as maintenance of personal and environmental hygiene and medication management. However, some participants narrated their experiences of stigma and thus, resorted to certain strategies such as spirituality, medication adherence and mental fortitude to cope with schizophrenia. In conclusion, it was evident that people with schizophrenia, in their lucid intervals, can undertake various activities of daily living, including personal care, however, living with schizophrenia impacts on psychological well-being enormously, and thus, education, counselling, and client adherence to the treatment may improve quality of life.

Internalized stigma mediates the relation between psychosis-risk symptoms and subjective quality of life in a help-seeking sample

Subjective quality of life can be compromised in individuals with psychosis-risk symptoms, with poorer quality of life being associated with worse functioning and later transition to psychosis. Individuals who experience psychosis-related symptoms also tend to endorse more internalized (or self-) mental health stigma when compared to controls, potentially contributing to delays in seeking treatment and increased duration of untreated psychosis, as well as interfering with treatment engagement and retention in those already receiving care. Despite these findings, and the growing recognition for prevention in earlier phases of psychotic illness, few studies have examined the relation between psychosis-risk symptoms, internalized stigma, and subjective quality of life in a younger, help-seeking sample. The present study examined whether internalized stigma mediates the relation between psychosis-risk symptoms and subjective quality of life in a transdiagnostic sample of youth (M age = 17.93, SD = 2.90) at clinical high-risk for psychosis (CHR), with early psychosis, or with non-psychotic disorders (N = 72). Psychosis-risk symptom severity was assessed using the Structured Interview for Psychosis-Risk Syndromes (SIPS). Internalized stigma was assessed using the Internalized Stigma of Mental Illness Inventory (ISMI), and subjective quality of life was assessed using the Youth Quality of Life Instrument - Short Form (YQOL-SF). Internalized stigma fully mediated the relation between psychosis-risk symptoms and subjective quality of life across the full sample (p < .05, f² = 0.06). Findings suggest that internalized stigma may be an important target in efforts to improve quality of life for individuals in early stages of psychosis.

Stigma, lost opportunities, and growth: Understanding experiences of caregivers of persons with mental illness in Tamil Nadu, India

This study aimed to address gaps in understanding of the lived experiences of caregivers of persons with mental illness in low-income countries. It was conducted among caregivers of persons with mental illness making use of a free non-governmental clinic in and around Chennai, India. The study adopted a qualitative methodology, with semi-structured interviews and life history exercises (n = 29) and six focus group discussions with caregivers (n = 21) and mental health professionals and community-based workers (n = 39). The experiences of caregivers were analyzed in the framework of "The Banyan model of caregiving," which identifies six phases. Major themes in caregivers' experience were: embarrassment and losing honor; fear; awareness; stigma and social exclusion; and reduced social interaction and loneliness. Posttraumatic growth considered as the result of caregiver experiences was found to consist mainly of personal growth and focusing on positive life experiences. Lost opportunities particular to the context of Tamil Nadu were described as the inability to get married, obtaining less education than desired, and loss of employment. Siblings faced lower levels of burden, while elderly mothers experienced especially high levels of burden and lack of happiness in life. Caregiver gains were identified as greater compassion for other people with disabilities, resulting in a desire to help others, as well as increased personal strength and confidence. Understanding the nuances of the caregiving experiences over time can provide a framework to devise more fine-tuned support structures that aim to prevent reductions in social interaction and lost opportunities, and improve a sense of meaning, in order to assist caregivers to continue providing care for their relatives with mental illness in a context with scarce mental health resources.

Whose responsibility? Part 1 of 2: A scale to assess how stakeholders apportion responsibilities for addressing the needs of persons with mental health problems

Background

Individuals with mental health problems have multiple, often inadequately met needs. Responsibility for meeting these needs frequently falls to patients, their families/caregivers, and governments. Little is known about stakeholders' views of who should be responsible for these needs and there are no measures to assess this construct. This study’s objectives were to present the newly designed Whose Responsibility Scale (WRS), which assesses how stakeholders apportion responsibility to persons with mental health problems, their families, and the government for addressing various needs of persons with mental health problems, and to report its psychometric properties.

Methods

The 22-item WRS asks respondents to assign relative responsibility to the government versus persons with mental health problems, government versus families, and families versus persons with mental health problems for seven support needs. The items were modelled on a World Values Survey item comparing the government’s and people’s responsibility for ensuring that everyone is provided for. We administered English, Tamil, and French versions to 57 patients, 60 family members, and 27 clinicians at two early psychosis programs in Chennai, India, and Montreal, Canada, evaluating test–retest reliability, internal consistency, and ease of use. Internal consistency estimates were also calculated for confirmatory purposes with the larger samples from the main comparative study.

Results

Test–retest reliability (intra-class correlation coefficients) generally ranged from excellent to fair across stakeholders (patients, families, and clinicians), settings (Montreal and Chennai), and languages (English, French, and Tamil). In the standardization and larger confirmatory samples, internal consistency estimates (Cronbach’s alphas) ranged from acceptable to excellent. The WRS scored average on ease of comprehension and completion. Scores were spread across the 1–10 range, suggesting that the scale captured variations in views on how responsibility for meeting needs should be distributed. On select items, scores at one end of the scale were never endorsed, but these reflected expected views about specific needs (e.g., Chennai patients never endorsed patients as being substantially more responsible for housing needs than families).

Conclusions

The WRS is a promising measure for use across geo-cultural contexts to inform mental health policies, and to foster dialogue and accountability among stakeholders about roles and responsibilities. It can help researchers study stakeholders’ views about responsibilities, and how these shape and are shaped by sociocultural contexts and mental healthcare systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-021-00510-x.

Perceived Course of Illness on the Desire for Social Distance From People Suffering From Symptoms of Schizophrenia in India

BACKGROUND

Stigmatization of people with schizophrenia remains a highly relevant topic worldwide, particularly in low- and middle-income countries like India. It is crucial to identify the determinants of the desire for social distance as a proxy for discriminatory behavior in a socio-cultural context to indicate ways to reduce stigma. This study aims to explore whether the public perception of the perceived course of an illness concerning people with symptoms of schizophrenia has an impact on the desire for social distance.

SUBJECTS AND METHODS

Data collection took place in five cities in India. The sample (N = 447) was stratified for gender, age, and religion. Desire for social distance was sampled based on a self-reported questionnaire using unlabelled vignettes for schizophrenia. First, factor analysis was conducted to identify the main factors underlying the perception of the perceived course of the illness. Subsequently, a regression analysis was conducted to examine the impact of the perception of those prognostic factors on the desire for social distance.

RESULTS

Factor analysis revealed two independent factors of the perceived course of an illness: (1) life-long dependency on others and loss of social integration and functioning and (2) positive expectations toward treatment outcome. This second factor was significantly associated with a less desire for social distance toward persons with schizophrenia.

CONCLUSION

The desire for social distance toward people with schizophrenia reduces with the expectation of positive treatment outcomes which underlines the need to raise public mental health awareness and provide psychoeducation for affected people and their family members in India. Help-seeking behaviors can be promoted by directing those needing treatment toward locally available, affordable and credible community-based services rather than facility-based care. Strikingly, lifelong dependency and the inability to socially integrate do not increase the desire for social distance, reflecting the Indian nation's socio-relational values and insufficiency of public mental health services. This indicates the suitability of systemic therapy approaches in public mental healthcare services to support the family's involvement and family-based interventions in caregiving for mentally ill people across the lifespan.

Culturally Adapted Psychoeducation among Family Caregivers of Schizophrenic Clients: A Scoping Review

Background: As psychoeducation was originally developed from Western, this intervention should be integrated with a culture to obtain effective outcomes. However, how culturally adapted psychoeducation on family caregivers of schizophrenic client developed in previous studies has not been systematically documented. The purpose of this review was to map culturally adapted psychoeducation in previous studies. Methods: This scoping review followed Arksey & O'Malley approach. Inclusion criteria including family caregiver, culture, psychoeducation, schizophrenia. Non-primary and non-experiment studies, non-English language and non-free articles were excluded. Advanced search technique used keywords family caregiver, culture, psychoeducation, schizophrenia on CINAHL, PubMed, and PsycInfo databases. Screening was done by checking duplication, title, and abstract. Full text of relevant articles was read in detail to select eligible articles. Selection results were described in the PRISMA flow chart. Data were analyzed after these were extracted and resumed on the table.   Result: A total of 8 studies were included in this review. More than half of  articles used randomized control trial (RCT) but these studies did not conduct follow up. Most of studies were  in Asia (6) and it conducted  in the outpatient department (6). Almost all studies modified multifamily group psychoeducation with culture theories. The longest duration of intervention was 12 months. Multidiscipline health professional delivered the intervention and most of the were psychiatrist. Coping was the most family caregiver outcomes in reviewed studies. Conclusion: In conclusion, limited studies were obtained in various ethnics and ways. Further studies need to measure effectiveness of the intervention in long term effect.  

Perspectives of healthcare providers, service users, and family members about mental illness stigma in primary care settings: A multi-site qualitative study of seven countries in Africa, Asia, and Europe

BACKGROUND

Stigma among healthcare providers is a barrier to the effective delivery of mental health services in primary care. Few studies have been conducted in primary care settings comparing the attitudes of healthcare providers and experiences of people with mental illness who are service users in those facilities. Such research is necessary across diverse global settings to characterize stigma and inform effective stigma reduction.

METHODS

Qualitative research was conducted on mental illness stigma in primary care settings in one low-income country (Nepal), two lower-middle income countries (India, Tunisia), one upper-middle-income country (Lebanon), and three high-income countries (Czech Republic, Hungary, Italy). Qualitative interviews were conducted with 248 participants: 64 primary care providers, 11 primary care facility managers, 111 people with mental illness, and 60 family members of people with mental illness. Data were analyzed using framework analysis.

RESULTS

Primary care providers endorsed some willingness to help persons with mental illness but reported not having appropriate training and supervision to deliver mental healthcare. They expressed that people with mental illness are aggressive and unpredictable. Some reported that mental illness is incurable, and mental healthcare is burdensome and leads to burnout. They preferred mental healthcare to be delivered by specialists. Service users did not report high levels of discrimination from primary care providers; however, they had limited expectations of support from primary care providers. Service users reported internalized stigma and discrimination from family and community members. Providers and service users reported unreliable psychiatric medication supply and lack of facilities for confidential consultations. Limitations of the study include conducting qualitative interviews in clinical settings and reliance on clinician-researchers in some sites to conduct interviews, which potentially biases respondents to present attitudes and experiences about primary care services in a positive manner.

CONCLUSIONS

Primary care providers' willingness to interact with people with mental illness and receive more training presents an opportunity to address stigmatizing beliefs and stereotypes. This study also raises important methodological questions about the most appropriate strategies to accurately understand attitudes and experiences of people with mental illness. Recommendations are provided for future qualitative research about stigma, such as qualitative interviewing by non-clinical personnel, involving non-clinical staff for recruitment of participants, conducting interviews in non-clinical settings, and partnering with people with mental illness to facilitate qualitative data collection and analysis.

Prevalence and predictive factors of strain among caregivers of people with disability: results from R-Care community survey, Kerala, India

PURPOSE

Caregivers of people with disability experience difficulties in a variety of care domains. Understanding the predictive factors of caregiver strain is important in developing and implementing evidence-based intervention to reduce the difficulties experienced by the carers.

METHODS

The current study is a cross sectional comprehensive one-phase survey conducted in randomly selected sub-districts (taluks) of the Ernakulam district in Kerala. Primary caregivers (n = 851) for persons with different kinds of disability were identified with the help of ASHAs (Accredited Social Health Activities) from the selected geographical locations and were interviewed in a house-to-house survey after obtaining written informed consent. Validated tools measuring caregiver strain, financial burden, access to services and wellbeing were used to study the population.

RESULTS

Majority of the caregivers were females (77.3%) and spouses (35.2%). Of the caregivers 27% reported high levels of caregiver strain. The major factors associated with caregiver strain were female gender (B = 1.379, p = 0.000), financial issues (B = 0.105, p = 0.000), the general health of caregivers (B = 0.467, p = 0.000) and issues relating to employment (B = 0.956, p = 0.000) and the availability of government welfare services (B = 1.138, p = 0.000).

CONCLUSION

High caregiver burden and strain is experienced by almost a third of people caring for a person with a disability. Comprehensive interventions to reduce caregiver strain should be developed.Implications for rehabilitationThe rehabilitation sector needs to be made aware of the high levels of caregiver strain (especially in carers who were female, unemployed, have health issues and lack formal support).To improve wellbeing for people with disability we firstly need to promote social inclusion and support schemes for caregiver.Co-designed systems are needed to assist carers to access formal and informal support resources, and increase social connectedness.

Self-stigma in Serious Mental Illness: A Systematic Review of Frequency, Correlates, and Consequences

Self-stigma is associated with poor clinical and functional outcomes in Serious Mental Illness (SMI). There has been no review of self-stigma frequency and correlates in different cultural and geographic areas and SMI. The objectives of the present study were: (1) to review the frequency, correlates, and consequences of self-stigma in individuals with SMI; (2) to compare self-stigma in different geographical areas and to review its potential association with cultural factors; (3) to evaluate the strengths and limitations of the current body of evidence to guide future research. A systematic electronic database search (PubMed, Web of Science, PsycINFO, Scopus, and Ovid SP Cumulative Index to Nursing and Allied Health Literature [CINAHL]) following PRISMA guidelines, was conducted on the frequency, correlates, and consequences of self-stigma in SMI. Out of 272 articles, 80 (29.4%) reported on the frequency of self-stigma (n = 25 458), 241 (88.6%) on cross-sectional correlates of self-stigma and 41 (15.0%) on the longitudinal correlates and consequences of self-stigma. On average, 31.3% of SMI patients reported high self-stigma. The highest frequency was in South-East Asia (39.7%) and the Middle East (39%). Sociodemographic and illness-related predictors yielded mixed results. Perceived and experienced stigma-including from mental health providers-predicted self-stigma, which supports the need to develop anti-stigma campaigns and recovery-oriented practices. Increased transition to psychosis and poor clinical and functional outcomes are both associated with self-stigma. Psychiatric rehabilitation and recovery-oriented early interventions could reduce self-stigma and should be better integrated into public policy.

Primary-level worker interventions for the care of people living with mental disorders and distress in low- and middle-income countries

BACKGROUND

Community-based primary-level workers (PWs) are an important strategy for addressing gaps in mental health service delivery in low- and middle-income countries.  OBJECTIVES: To evaluate the effectiveness of PW-led treatments for persons with mental health symptoms in LMICs, compared to usual care.  SEARCH METHODS: MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, ICTRP, reference lists (to 20 June 2019).   SELECTION CRITERIA: Randomised trials of PW-led or collaborative-care interventions treating people with mental health symptoms or their carers in LMICs.  PWs included: primary health professionals (PHPs), lay health workers (LHWs), community non-health professionals (CPs).  DATA COLLECTION AND ANALYSIS: Seven conditions were identified apriori and analysed by disorder and PW examining recovery, prevalence, symptom change, quality-of-life (QOL), functioning, service use (SU), and adverse events (AEs).  Risk ratios (RRs) were used for dichotomous outcomes; mean difference (MDs), standardised mean differences (SMDs), or mean change differences (MCDs) for continuous outcomes.  For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥0.80 large clinical effects.  Analysis timepoints: T1 (<1 month), T2 (1-6 months), T3 ( >6 months) post-intervention.  MAIN RESULTS: Description of studies 95 trials (72 new since 2013) from 30 LMICs (25 trials from 13 LICs).  Risk of bias Most common: detection bias, attrition bias (efficacy), insufficient protection against contamination.  Intervention effects *Unless indicated, comparisons were usual care at T2.  "Probably", "may", or "uncertain" indicates "moderate", "low," or "very low" certainty evidence.   Adults with common mental disorders (CMDs) LHW-led interventions a. may increase recovery (2 trials, 308 participants; RR 1.29, 95%CI 1.06 to 1.56); b. may reduce prevalence (2 trials, 479 participants; RR 0.42, 95%CI 0.18 to 0.96); c. may reduce symptoms (4 trials, 798 participants; SMD -0.59, 95%CI -1.01 to -0.16); d. may improve QOL (1 trial, 521 participants; SMD 0.51, 95%CI 0.34 to 0.69); e. may slightly reduce functional impairment (3 trials, 1399 participants; SMD -0.47, 95%CI -0.8 to -0.15); f. may reduce AEs (risk of suicide ideation/attempts); g. may have uncertain effects on SU. Collaborative-care a. may increase recovery (5 trials, 804 participants; RR 2.26, 95%CI 1.50 to 3.43); b. may reduce prevalence although the actual effect range indicates it may have little-or-no effect (2 trials, 2820 participants; RR 0.57, 95%CI 0.32 to 1.01); c. may slightly reduce symptoms (6 trials, 4419 participants; SMD -0.35, 95%CI -0.63 to -0.08); d. may slightly improve QOL (6 trials, 2199 participants; SMD 0.34, 95%CI 0.16 to 0.53); e. probably has little-to-no effect on functional impairment (5 trials, 4216 participants; SMD -0.13, 95%CI -0.28 to 0.03); f. may reduce SU (referral to MH specialists);  g. may have uncertain effects on AEs (death). Women with perinatal depression (PND) LHW-led interventions a. may increase recovery (4 trials, 1243 participants; RR 1.29, 95%CI 1.08 to 1.54); b. probably slightly reduce symptoms (5 trials, 1989 participants; SMD -0.26, 95%CI -0.37 to -0.14); c. may slightly reduce functional impairment (4 trials, 1856 participants; SMD -0.23, 95%CI -0.41 to -0.04); d. may have little-to-no effect on AEs (death);  e. may have uncertain effects on SU. Collaborative-care a. has uncertain effects on symptoms/QOL/SU/AEs. Adults with post-traumatic stress (PTS) or CMDs in humanitarian settings LHW-led interventions a. may slightly reduce depression symptoms (5 trials, 1986 participants; SMD -0.36, 95%CI -0.56 to -0.15); b. probably slightly improve QOL (4 trials, 1918 participants; SMD -0.27, 95%CI -0.39 to -0.15); c. may have uncertain effects on symptoms (PTS)/functioning/SU/AEs. PHP-led interventions a. may reduce PTS symptom prevalence (1 trial, 313 participants; RR 5.50, 95%CI 2.50 to 12.10) and depression prevalence (1 trial, 313 participants; RR 4.60, 95%CI 2.10 to 10.08);  b. may have uncertain effects on symptoms/functioning/SU/AEs.   Adults with harmful/hazardous alcohol or substance use LHW-led interventions a. may increase recovery from harmful/hazardous alcohol use although the actual effect range indicates it may have little-or-no effect (4 trials, 872 participants; RR 1.28, 95%CI 0.94 to 1.74); b. may have little-to-no effect on the prevalence of methamphetamine use (1 trial, 882 participants; RR 1.01, 95%CI 0.91 to 1.13) and  functional impairment (2 trials, 498 participants; SMD -0.14, 95%CI -0.32 to 0.03); c. probably slightly reduce risk of harmful/hazardous alcohol use (3 trials, 667 participants; SMD -0.22, 95%CI -0.32 to -0.11);  d. may have uncertain effects on SU/AEs. PHP/CP-led interventions a. probably have little-to-no effect on recovery from harmful/hazardous alcohol use (3 trials, 1075 participants; RR 0.93, 95%CI 0.77 to 1.12) or QOL (1 trial, 560 participants; MD 0.00, 95%CI -0.10 to 0.10); b. probably slightly reduce risk of harmful/hazardous alcohol and substance use (2 trials, 705 participants; SMD -0.20, 95%CI -0.35 to -0.05; moderate-certainty evidence); c. may have uncertain effects on prevalence (cannabis use)/SU/AEs. PW-led interventions for alcohol/substance dependence a. may have uncertain effects.  Adults with severe mental disorders *Comparisons were specialist-led care at T1. LHW-led interventions a. may have little-to-no effect on caregiver burden (1 trial, 253 participants; MD -0.04, 95%CI -0.18 to 0.11);  b. may have uncertain effects on symptoms/functioning/SU/AEs.  PHP-led or collaborative-care a. may reduce functional impairment (7 trials, 874 participants; SMD -1.13, 95%CI -1.78 to -0.47); b. may have uncertain effects on recovery/relapse/symptoms/QOL/SU.  Adults with dementia and carers PHP/LHW-led carer interventions a. may have little-to-no effect on the severity of behavioural symptoms in dementia patients (2 trials, 134 participants; SMD -0.26, 95%CI -0.60 to 0.08); b. may reduce carers' mental distress (2 trials, 134 participants; SMD -0.47, 95%CI -0.82 to -0.13);  c. may have uncertain effects on QOL/functioning/SU/AEs. Children with PTS or CMDs LHW-led interventions a. may have little-to-no effect on PTS symptoms (3 trials, 1090 participants; MCD -1.34, 95%CI -2.83 to 0.14); b. probably have little-to-no effect on depression symptoms (3 trials, 1092 participants; MCD -0.61, 95%CI -1.23 to 0.02) or on functional impairment (3 trials, 1092 participants; MCD -0.81, 95%CI -1.48 to -0.13);  c. may have little-or-no effect on AEs. CP-led interventions a. may have little-to-no effect on depression symptoms (2 trials, 602 participants; SMD -0.19, 95%CI -0.57 to 0.19) or on AEs;  b. may have uncertain effects on recovery/symptoms(PTS)/functioning.

AUTHORS' CONCLUSIONS

PW-led interventions show promising benefits in improving outcomes for CMDs, PND, PTS, harmful alcohol/substance use, and dementia carers in LMICs.

Adaptation of the World Health Organization Electronic Mental Health Gap Action Programme Intervention Guide App for Mobile Devices in Nepal and Nigeria: Protocol for a Feasibility Cluster Randomized Controlled Trial

BACKGROUND

There is a growing global need for scalable approaches to training and supervising primary care workers (PCWs) to deliver mental health services. Over the past decade, the World Health Organization Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) and associated training and implementation guidance have been disseminated to more than 100 countries. On the basis of the opportunities provided by mobile technology, an updated electronic Mental Health Gap Action Programme Intervention Guide (e-mhGAP-IG) is now being developed along with a clinical dashboard and guidance for the use of mobile technology in supervision.

OBJECTIVE

This study aims to assess the feasibility, acceptability, adoption, and other implementation parameters of the e-mhGAP-IG for diagnosis and management of depression in 2 lower-middle-income countries (Nepal and Nigeria) and to conduct a feasibility cluster randomized controlled trial (cRCT) to evaluate trial procedures for a subsequent fully powered trial comparing the clinical effectiveness and cost-effectiveness of the e-mhGAP-IG and remote supervision with standard mhGAP-IG implementation.

METHODS

A feasibility cRCT will be conducted in Nepal and Nigeria to evaluate the feasibility of the e-mhGAP-IG for use in depression diagnosis and treatment. In each country, an estimated 20 primary health clinics (PHCs) in Nepal and 6 PHCs in Nigeria will be randomized to have their staff trained in e-mhGAP-IG or the paper version of mhGAP-IG v2.0. The PHC will be the unit of clustering. All PCWs within a facility will receive the same training (e-mhGAP-IG vs paper mhGAP-IG). Approximately 2-5 PCWs, depending on staffing, will be recruited per clinic (estimated 20 health workers per arm in Nepal and 15 per arm in Nigeria). The primary outcomes of interest will be the feasibility and acceptability of training, supervision, and care delivery using the e-mhGAP-IG. Secondary implementation outcomes include the adoption of the e-mhGAP-IG and feasibility of trial procedures. The secondary intervention outcome-and the primary outcome for a subsequent fully powered trial-will be the accurate identification of depression by PCWs. Detection rates before and after training will be compared in each arm.

RESULTS

To date, qualitative formative work has been conducted at both sites to prepare for the pilot feasibility cRCT, and the e-mhGAP-IG and remote supervision guidelines have been developed.

CONCLUSIONS

The incorporation of mobile digital technology has the potential to improve the scalability of mental health services in primary care and enhance the quality and accuracy of care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04522453; https://clinicaltrials.gov/ct2/show/NCT04522453.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/24115.

Warwick-India-Canada (WIC) global mental health group: rationale, design and protocol

INTRODUCTION

The primary aim of the National Institute of Health Research-funded global health research group, Warwick-India-Canada (WIC), is to reduce the burden of psychotic disorders in India. India has a large pool of undetected and untreated patients with psychosis and a treatment gap exceeding 75%. Evidence-based packages of care have been piloted, but delivery of treatments still remains a challenge. Even when patients access treatment, there is minimal to no continuity of care. The overarching ambition of WIC programme is to improve patient outcomes through (1) developing culturally tailored clinical interventions, (2) early identification and timely treatment of individuals with mental illness and (3) improving access to care by exploiting the potential of digital technologies.

METHODS AND ANALYSIS

This multicentre, multicomponent research programme, comprising five work packages and two cross-cutting themes, is being conducted at two sites in India: Schizophrenia Research Foundation, Chennai (South India) and All India Institute of Medical Sciences, New Delhi (North India). WIC will (1) develop and evaluate evidence-informed interventions for early and first-episode psychosis; (2) determine pathways of care for early psychosis; (3) investigate the efficacy and cost-effectiveness of community care models, including digital and mobile technologies; (4) develop strategies to reduce the burden of mental illnesses among youth; (5) assess the economic burden of psychosis on patients and their carers; and (6) determine the feasibility of an early intervention in psychosis programme in India.

ETHICS AND DISSEMINATION

This study was approved by the University of Warwick's Biomedical and Scientific Research Ethics Committee (reference: REGO-2018-2208), Coventry, UK and research ethics committees of all participating organisations. Research findings will be disseminated through peer-reviewed scientific publications, presentations at learnt societies and visual media.

COVID-19 in India: Who are we leaving behind?

The COVID-19 pandemic has uncovered and intensified existing societal inequalities. People on the move and residents of urban slums and informal settlements are among some of the most affected groups in the Global South. Given the current living conditions of migrants, the WHO guidelines on how to prevent COVID-19 (such as handwashing, physical distancing and working from home) are challenging to nearly impossible in informal settlements. We use the case of India to highlight the challenges of migrants and urban slum dwellers during the COVID-19 response, and to provide human rights-based recommendations for immediate action to safeguard these vulnerable populations.

Comparing discrimination among people with schizophrenia, affective and anxiety disorders. A multilevel study in five European countries

BACKGROUND

Most research on mental illness stigma has involved people with psychosis; less information is available for people with affective and anxiety disorders. We aimed to compare experienced and anticipated discrimination among people with schizophrenia, and affective and anxiety disorders.

METHODS

People with schizophrenia (n=773), affective (n=1010) and anxiety disorders (n=372) were recruited during psychiatric admission across 5 EU countries. The Discrimination and Stigma Scale (DISC-12) was used. Multivariate mixed effect logistic regression models with a random effect for hospital and country were performed to explore patient characteristics associated with experienced and anticipated discrimination.

RESULTS

With anxiety disorders, there were more reports of experiences of discrimination in social life (35%), intimate relationships (23.5%), and physical healthcare (19%); in schizophrenia, in relations with neighbours (23.6%) and mental health staff (21.7%); and in affective disorders, in parental role (22.8%). In multivariate analyses, anxiety was associated with increased likelihood of experiencing discrimination in police interactions (OR=1.675; p=0.038) and physical healthcare (OR=1.816; p=0.003), and reduced likelihood when starting a family (OR=0.474; p=0.01) as compared with schizophrenia. Affective (OR=1.367; p=0.004) and anxiety disorders (OR=1.354; p=0.034) were associated with increased likelihood of concealing a diagnosis compared with schizophrenia.

LIMITATIONS

As patients with affective and anxiety disorders were recruited from hospital inpatient units, their experiences may not be representative of all people with these disorders.

CONCLUSIONS

In a sample of people receiving inpatient treatment, experienced and anticipated discrimination are perceived, at least in some life domains, as more of a burden for people with affective and anxiety disorders than those with schizophrenia.

Internalized Stigma among Bedouin and Jews with Mental Illness: Comparing Self-Esteem, Hope, and Quality of Life

The aim of this study was to assess the differences in internalized-stigma, self-esteem, hope, and quality of life in individuals with mental illness from two diverse cultures (Bedouins and Jews) and to examine the relationships between self-stigma and self-esteem, hope, and quality of life in participants from both cultures. Two hundred participants with mental illness in Israel were assessed on the Internalized Stigma of Mental Illness (ISMI) scale. The Arab Bedouin participants tended to internalize stigma to a greater extent than the Jewish participants. Overall, there was a significant negative correlation between self-stigma, self-esteem, and hope and between alienation and quality of life in both groups although the correlation was stronger among the Arab Bedouin participants. By contrast, the associations between self-stigma and quality of life were only significant for two of the self-stigma dimensions (alienation and discrimination) among the Jewish participants. These results contribute to a better understanding of the role internalized stigma may play in the life of people with mental illness from diverse cultures. They may help design culturally appropriate intervention programs for people with mental illness.

Employment functioning in people with severe mental illnesses living in urban vs. rural areas in India

PURPOSE

Research on employment in people with severe mental illnesses (SMI) in developing countries is sparse and largely limited to employment rates. We conducted a comprehensive study of work, interest in work, and perceived benefits and barriers to work in people with SMI in India.

METHODS

Semi-structured interviews were conducted with 550 individuals with SMI receiving private psychiatric outpatient services in two districts in western India, one urban (Pune) and the other rural (Ahmednagar).

RESULTS

More than half of the participants were employed, with significantly more men working (79.4%) than women (35.9%). Higher rates of work were found in rural areas (77.8%), where most work was in family agricultural businesses, than in urban areas (48.9%), where most work was for independent employers. Participants in rural areas worked fewer hours and earned less money, and reported fewer benefits and fewer problems related to work than urban participants. Over 45% of participants working for independent employers found jobs with help from families and extended social networks. Most unemployed participants wanted to work, and desired a variety of supports, including assistance with job finding and illness management.

CONCLUSIONS

Gender-specific social role expectations and families play an important role in work in people with SMI in India. Despite higher rates of work in this sample than most studies from developed countries, a significant subgroup was unemployed but wanted to work. Persons with SMI in developing countries may benefit from the adaptation of validated vocational rehabilitation approaches in developed countries to their cultural context.

Stigma associated with mental health problems among young people in India: a systematic review of magnitude, manifestations and recommendations

BACKGROUND

Globally, 20% of young people experience mental disorders. In India, only 7.3% of its 365 million youth report such problems. Although public stigma associated with mental health problems particularly affects help-seeking among young people, the extent of stigma among young people in India is unknown. Describing and characterizing public stigma among young people will inform targeted interventions to address such stigma in India, and globally. Thus, we examined the magnitude and manifestations of public stigma, and synthesised evidence of recommendations to reduce mental-health-related stigma among young people in India.

METHOD

A systematic review and meta-analysis of observational studies was conducted. Nine electronic databases were searched and 30 studies (n = 6767) met inclusion criteria.

RESULTS

Most studies (66%) focused on youth training to become health professionals. One-third of young people display poor knowledge of mental health problems and negative attitudes towards people with mental health problems and one in five had actual/intended stigmatizing behavior (I2>=95%). Young people are unable to recognize causes and symptoms of mental health problems and believe that recovery is unlikely. People with mental health problems are perceived as dangerous and irresponsible, likely due to misinformation and misunderstanding of mental health problems as being solely comprised of severe mental disorders (e.g. schizophrenia). However, psychiatric labels are not commonly used/understood.

CONCLUSION

Public education may use symptomatic vignettes (through relatable language and visuals) instead of psychiatric labels to improve young people's understanding of the range of mental health problems. Recommended strategies to reduce public stigma include awareness campaigns integrated with educational institutions and content relevant to culture and age-appropriate social roles.

The fight against stigma: Multilevel stigma interventions in schizophrenia patients

Background: Stigma is one of the main factors causing pasung (physical restraint or confinement in Indonesian terms) in schizophrenia patients. It is the main obstacle to reducing the number of pasung throughout the world. Thus, there is a need for appropriate interventions to reduce stigma in schizophrenia patients who go through pasung. This study aims to identify multilevel stigma interventions in people with schizophrenia who go through pasung (physical restraint and confinement). It can be applied and adapted to various cultural contexts.

Design and Methods: Quasi-experimental research with pretest and post-test analysis consists of 82 people with schizophrenia who go through pasung. Respondents were divided into the intervention group and the control group. A multilevel stigma intervention was given to the intervention group for three months.

Results: There was a significant difference in the average stigma score in the control group (moderate category stigma) and the intervention group (mild category stigma) after multilevel stigma intervention (p-value = 0.04). The average stigma score of schizophrenia patients in the intervention group decreased by 8.2%, while the average stigma score in the control group increase of 20.4%.

Conclusions: Multilevel stigma interventions are effective in reducing stigma in people with schizophrenia who go through pasung. We underline that multilevel stigma interventions through collaboration from various parties can provide great opportunities in stigma reduction programs in people with schizophrenia who go through pasung.

The process of responding to stigma in people with schizophrenia spectrum disorders and families: A grounded theory study

BACKGROUND

The way people with schizophrenia spectrum disorders and families address stigma has a significant role in their vulnerability to this distressing phenomenon. However, there is little knowledge about this issue in Middle Eastern countries.

PURPOSE

Exploring the process of addressing stigma in people with schizophrenia spectrum disorders and families.

DESIGN AND METHODS

In our grounded theory study, we interviewed seven patients and nine family members and used a constant comparative analysis approach for data analysis.

FINDINGS

The participants expressed being socially rejected and oppressed by others. In addressing stigma, the patients and families surrendered passively and reluctantly. This main strategy sometimes led to deprivation and isolation and sometimes resulted in lessening their tension.

PRACTICE IMPLICATIONS

Mental health nurses can empower patients and families with the skills necessary to counter stigma and, in this way, modify the sense of disability as an obstacle to stigma resistance. Also, mental health nurses can modify the contextual factors of stigma by initiating campaigns, educating society members, and involving them in fighting stigma.

Stigma in mental illness: Perspective from eight Asian nations

BACKGROUND

Stigma against those who suffer from mental illness is a major issue in many nations. Stigma, which is comprised of prejudice, ignorance, and discrimination, serves as a barrier to seeking help and staying in contact with mental health services. It is thus imperative that concerted efforts are taken against stigma.

METHODS

Eight young psychiatrists from eight Asian nations offer a narrative review of the state of stigma in their respective nations, the sociocultural reasons behind this stigma, recent anti-stigma efforts and the effects, if any, of such efforts.

RESULTS

Despite these eight nations lying varying significantly in terms of economic developmental levels, there are sociocultural commonalities that undergird stigma across these nations. It is also evident that there have been more recent concerted efforts to combat this stigma, and in some countries, there has been a change in the perceptions of mental illness.

CONCLUSION

The causes of stigma tend to be similar across various nations, and this perhaps suggests that international collaboration and a concerted global effort to combat this problem might thus be a possibility.