Mental illness disclosure in Chinese immigrant communities

Negotiating familial mental illness stigma: The role of family members of persons living with mental illnesses

BACKGROUND

This study explores how family members of individuals with mental illnesses address potential familial mental illness stigma. Previous studies have concentrated on self, social, and associative stigma and its impacts on families and persons with mental illnesses. Far less work has considered family members as perpetrators of mental illness stigma towards their loved ones with mental illnesses.

METHODOLOGY/PRINCIPAL FINDINGS

We conducted this study with 15 participants who were family members of persons with mental illnesses using semi-structured qualitative interviews. The in-depth interviews were followed by inductive analysis using Braun and Clarke's technique for thematic analysis. Participants' views on familial mental illness stigma and ways to reduce this were reported in five key themes. The themes included: (1) layered perspectives of social and family stigma; (2) family-related stigma; (3) complex interplay of family relationships and mental illness; (4) confronting stigma personally; and (5) envisioning a better future. The uncertainties connected with mental illnesses and the increased social stigma were conceptualized as contributors to familial mental illness stigma as ways to prevent potential associative stigma.

CONCLUSION/SIGNIFICANCE

Participants suggested the need for more social contact-based education and positive media reporting to correct the ongoing fallacies around mental illnesses. This study highlights how higher-order reforms to social systems and services would support both families and those living with mental illnesses to have more positive experiences.

Indian immigrants' constructions of mental health and mental illness in the perinatal period: A qualitative study

AIM

The aim of this study is to explore how immigrant women and men from India construct mental health and mental illness in the perinatal period.

DESIGN

Qualitative interpretive design.

METHODS

Data were collected by conducting in-depth interviews with 19 participants. Photo elicitation, free listing and pile sorting were used during the interviews. Purposive sampling was used, and data were collected in 2018 and 2019. Data were analysed using thematic analysis.

FINDING/RESULTS

One major theme and three subthemes were identified. 'We do not talk about it' was the major theme and the subthemes: (1) 'living peacefully and feeling happy' described the views on mental health; (2) 'that's the elephant in the room still' captures how participants felt when talking about mental illness; and (3) 'why don't we talk about it' offers reasons why the Indian community does not talk about mental health and illness.

CONCLUSION

The findings of this study have highlighted the importance of understanding the impact of immigration and being culturally sensitive when assessing mental health in the perinatal period.

IMPACT

The findings of this study identify some of the reasons for non-disclosure of mental health issues by immigrants. Incorporating these findings during psychosocial assessment by health professionals in the perinatal period will help translate the cultural aspects into more effective communication.

PATIENT OR PUBLIC CONTRIBUTION

Patient and public contribution to the study was provided by the Community Stakeholders Group; these were members of the immigrant community from India who had expertise in mental health. They contributed to the study design and the key terms and phrases for the free list used in interviews.

Understanding the factors related to how East and Southeast Asian immigrant youth and families access mental health and substance use services: A scoping review

The objective of the review is to identify factors related to how East and Southeast Asian immigrant youth aged 12-24 and their families access mental health and substance use (MHSU) services. To address how East and Southeast Asian youth and their families access mental health and substance use services, a scoping review was conducted to identify studies in these databases: PubMed, MEDLINE (Ovid), EMBASE (Ovid), PsychINFO, CINAHL, and Sociology Collection. Qualitative content analysis was used to deductively identify themes and was guided by Bronfenbrenner's Ecological Systems Theory, the process-person-context-time (PPCT) model, and the five dimensions of care accessibility (approachability, acceptability, availability and accommodation, appropriateness, affordability). Seventy-three studies met the inclusion criteria. The dimensions of healthcare accessibility shaped the following themes: 1) Acceptability; 2) Appropriateness; 3) Approachability; 4) Availability and Accommodation. Bronfenbrenner's Ecological Systems Theory and the PPCT model informed the development of the following themes: 1) Immediate Environment/Proximal Processes (Familial Factors, Relationships with Peers; 2) Context (School-Based Services/Community Resources, Discrimination, Prevention, Virtual Care); 3) Person (Engagement in Services/Treatment/Research, Self-management); 4) Time (Immigration Status). The study suggests that there is a growing body of research (21 studies) focused on identifying acceptability factors, including Asian cultural values and the model minority stereotype impacting how East and Southeast Asian immigrant youth access MHSU services. This review also highlighted familial factors (16 studies), including family conflict, lack of MHSU literacy, reliance on family as support, and family-based interventions, as factors affecting how East and Southeast Asian immigrant youth access MHSU care. However, the study also highlighted a dearth of research examining how East and Southeast Asian youth with diverse identities access MHSU services. This review emphasizes the factors related to the access to MHSU services by East and Southeast Asian immigrant youth and families while providing insights that will improve cultural safety.

Contexts Matter in 'a Distress Shared Is a Distress Halved': A Meta-Analysis of Distress Sharing-Psychological Distress Relations

Can 'a distress shared is a distress halved' be universally applied? The relationship between sharing distress with others and individuals' psychological health may oscillate depending on how and where it is shared. This meta-analysis aimed to examine (1) whether the relationship between sharing distress and psychological distress is moderated by the manner of sharing (i.e. general tendency to share distress with others [general distress sharing] vs. ruminatively fixating on the negatives during the sharing [co-rumination]) and (2) cultural context (Eastern vs. Western). A total of 110 effect sizes from 105 studies (91 articles on general distress sharing and 84 articles on co-rumination) were included in the analysis with sharing manner as a moderator. For the cross-cultural analyses, 61 studies were included with 47 studies conducted in Western cultures and 15 studies conducted in Eastern cultures. Whereas generally sharing distress was negatively related to psychological distress, co-rumination showed a positive correlation with psychological distress. Culture significantly moderated co-rumination but not general distress sharing in relation to psychological distress. General distress sharing was consistently associated with decreased psychological distress across cultures. In contrast, co-rumination was related to deleterious psychological health only among Westerners, while Easterners showed a non-significant association with psychological distress. Our results align with the increasing importance of taking contextual factors into account in the field of emotion regulation literature.

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.

Experiences of familial stigma among individuals living with mental illnesses: A meta-synthesis of qualitative literature from high-income countries

WHAT IS KNOWN ON THE SUBJECT?: Mental illness stigma has been long acknowledged as a social problem that continues to persist and contribute to social exclusion of affected persons globally. Researchers have explored mental illness stigma in the general public and among health professionals, with little focus on stigma from family members and close relatives of persons with mental illnesses. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study appears to be the first meta-synthesis of familial mental illness stigma in high-income countries. Family members or close relatives of persons with mental illnesses may be perpetrators of stigma. That is, the family may enact stigma of mental illness against their relative to "save face" or by avoiding or narrowing their social contacts. Familial stigma is harmful due to the likely disaffection it brings within one's home environment. Familial mental stigma from the existing literature seems to be a by-product of public stigma and stigma by association WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Further research is necessary to look at the existence of familial mental illness stigma as well as available policies to reduce its impact on affected individuals in high-income countries. Researchers in high-income countries should endeavour to examine the relationship between familial, public and associative stigma to establish baseline metrics to inform future anti-stigma programs seeking to reduce familial mental illness stigma.

ABSTRACT

INTRODUCTION: Familial mental illness stigma is a pervasive issue but very subtle in high-income countries. Familial mental illness stigma implies persons living with mental illnesses are discriminated against by their family members or close relatives.

AIM/QUESTION

This meta-synthesis explored the experiences of familial stigma among individuals living with mental illnesses in high-income countries, focusing on empirical literature, to understand the breadth of current literature and ways to reduce this form of stigma.

METHOD

We conducted a meta-synthesis through a structured search of qualitative data from six electronic databases (Sociological Abstract, CINAHL, Medline, PsycINFO, Google Scholar and Embase). Inclusion criteria comprised: empirical primary research, primary technique for data collection is qualitative, studies published in a peer-reviewed journal in the English language between 2000 and 2020, studies reported on experiences of familial mental illness stigma, and studies conducted in high-income countries. The exclusion criteria were as follows: all grey literature, studies not written in English and non-peer-reviewed, studies not focused on familial mental illness stigma, quantitative peer-reviewed articles on the related concept and peer-reviewed articles on the related topic before the year 2000.

RESULTS

The study identified only 28 peer-reviewed articles on the topic within two decades. Concealment of familial stigma was found to be detrimental due to the potential for alienation within one's home environment. Disclosure and social contact within the family system were considered as critical interventions to provide some safety nets for individuals with mental illnesses.

DISCUSSION AND IMPLICATIONS FOR PRACTICE

The paucity of studies over the review period highlights the need for further attention to support optimal environments for persons living with mental illnesses. Families' understanding of the difficulties of mental illness stigma is vital to supporting the development of policies and interventions towards the avoidance of social exclusion within societies. Families should make concerted efforts to reduce stigma, and this includes within the family system. Education and training approaches around mental illness-related stigma should involve individuals with lived experience and their families, as well as service providers and the general public.

The Mental Health Benefit of Friend Networks in Older Korean Americans: The Conditioning Effect of Family Type

OBJECTIVES

We identified types of family relationships of older Korean Americans and examined how the mental health benefit of friend networks might be conditioned by family type.

METHODS

Data were from 2,070 participants in the Study of Older Korean Americans, a multistate survey of Korean immigrants aged 60 and older (Mage = 73.3, standard deviation [SD] = 8.01). To identify family types, latent profile analysis (LPA) was performed with marital status, living arrangement, family network, positive and negative interactions with family members, and family mistreatment. Linear regression models examined how mental distress was associated with friend networks and family types, as well as their interactions.

RESULTS

LPA identified 5 family types: close-knit, intimate but distant, detached, connected but dysfunctional, and dysfunctional. Greater distress was associated with smaller friend networks and belonging to the detached, connected but dysfunctional, and dysfunctional family types in comparison to the close-knit type. The interaction model showed that people in the connected but dysfunctional and dysfunctional groups had a stronger association between friend networks and mental distress than the counterparts in the close-knit group.

DISCUSSION

We not only confirmed the health-promoting role of friend networks and the value of a close-knit family but also found that the benefit of friend networks was pronounced when quality of the family relationship was impaired. Our findings called renewed attention to older immigrants' social convoys of family and friends, suggesting that the enhancement of friend networks could be particularly advantageous for older immigrants with dysfunctional family relationships.

Revealing Mental Health Information in Friendships: The Role of Disclosure Strategy and Perceived Recipient Response on Disclosure Outcomes

Processes of revealing, or disclosures, take various forms, and are sometimes referred to as disclosure strategies. How individuals share information influences how recipients respond, which may have important consequences that shape perceptions of the overall interaction and relationship satisfaction. This research explores mental health disclosures among friends to understand how (a) one's disclosure strategy predicts their perceptions of the recipient response, (b) perceived recipient response predicts perceptions of disclosure outcomes, and (c) perceived recipient response potentially mediates the relationships between disclosure strategies and disclosure outcomes (e.g., interaction success, relationship satisfaction). Participants were 144 individuals who had disclosed their mental health condition to a friend. Analyses revealed that when disclosing mental health information to a friend, strategy use was, in part, predictive of perceived recipient response which, in turn, predicted discloser's ratings of disclosure outcomes. This manuscript discusses implications of findings and suggests directions for future research.

The impact of China-to-US immigration on structural and cultural determinants of HIV-related stigma: implications for HIV care of Chinese immigrants

Objectives: Asian Americans have poor HIV-related outcomes, yet culturally salient barriers to care remain unclear, limiting development of targeted interventions for this group. We applied the 'what matters most' theory of stigma to identify structural and cultural factors that shape the nature of stigma before and after immigration from China to the US.Design: Semi-structured interviews were conducted with 16 immigrants to New York from China, recruited from an HIV clinic and community centers. Deductive followed by focal inductive qualitative analyses examined how Chinese cultural values (lian, guanxi, renqing) and structural factors influenced stigma before and after immigration.Results: In China, HIV stigma was felt through the loss of lian (moral status) and limited guanxi (social network) opportunities. A social structure characterized by limited HIV knowledge, discriminatory treatment from healthcare systems, and human rights violations impinged on the ability of people living with HIV to fulfill culturally valued goals. Upon moving to the US, positions of structural vulnerability shifted to enable maintenance of lian and formation of new guanxi, thus ameliorating aspects of stigma.Conclusions: HIV prevention and stigma reduction interventions among Chinese immigrants may be most effective by both addressing structural constraints and facilitating achievement of cultural values through clinical, peer, and group interventions.

Exploring mental illness stigma among Asian men mobilized to become Community Mental Health Ambassadors in Toronto Canada

BACKGROUND

Stigma of mental illness contributes to silence, denial and delayed help seeking. Existing stigma reduction strategies seldom consider gender and cultural contexts.

PURPOSE

The Strengths in Unity study was a multi-site Canadian study that engaged Asian men in three stigma reduction interventions (ACT, CEE, psychoeducation) and mobilized them as Community Mental Health Ambassadors. Our participants included both men living with or affected by mental illness (LWA) as well as community leaders (CL). This paper will: (1) describe the baseline characteristics of the Toronto participants including their sociodemographic information, mental illness stigma (CAMI and ISMI), attitudes towards social change (SJS), and intervention-related process variables (AAQ-II, VLQ, FMI, Empowerment); (2) compare the differences among these variables between LWA and CL; and (3) explore factors that may correlate with socio-economic status and mental health stigma.

RESULTS

A total of 609 Asian men were recruited in Toronto, Canada. Both CL and LWA had similar scores on measures of external and internalized stigma and social change attitudes, except that LWA had more positive views about the acceptance and integration of those with mental illness into the community on the CAMI, while CL had a higher level of perceived behavioral control on the SJS. Group differences were also observed between LWA and CL in some process-related variables. Exploratory analysis suggests that younger and more educated participants had lower stigma.

CONCLUSION

Our findings underscore the importance of engaging both community leaders and people with lived experience as mental health advocates to address stigma.

Systematic Review of Cultural Aspects of Stigma and Mental Illness among Racial and Ethnic Minority Groups in the United States: Implications for Interventions

Stigma is integral to understanding mental health disparities among racial and ethnic minority groups in the United States. We conducted a systematic review to identify empirical studies on cultural aspects of mental illness stigma (public, structural, affiliative, self) among three racial and ethnic minority groups (Asian Americans, Black Americans, Latinx Americans) from 1990 to 2019, yielding 97 articles. In comparison studies (N = 25), racial and ethnic minority groups often expressed greater public and/or self-stigma than White American groups. In within-group studies (N = 65; Asian American, n = 21; Black American, n = 18; Latinx American; n = 26), which were primarily qualitative (73%), four major cultural themes emerged: 1) service barriers including access and quality (structural stigma); 2) family experiences including concealment for family's sake, fear of being a burden, and stigma extending to family (affiliative stigma); 3) lack of knowledge about mental illness and specific cultural beliefs (public stigma); and 4) negative emotional responses and coping (self-stigma). These findings confirmed stigma has both similar and unique cultural aspects across groups. Despite this, few studies tested stigma reduction interventions (N = 7). These cultural insights can inform contextual change at the health systems and community levels to reduce stigma, and empowerment at the interpersonal and individual levels to resist stigma.

The effects of patient personality traits and family cohesion on the treatment delay for patients with first-episode schizophrenia spectrum disorder

AIM

The duration of untreated psychosis (DUP) is an important prognostic indicator of schizophrenia. We explored the effects of patient personality and family relationships on delayed schizophrenia treatment.

METHODS

We prospectively included data from 169 patients diagnosed with first-episode schizophrenia. Personality traits were investigated using the Big Five Inventory (BFI-10) and family relationship was assessed employing the Family Adaptability and Cohesion Evaluation Scale-III (FACES-III). We explored patient clinical characteristics using the Positive and Negative Syndrome Scale (PANSS) and the Social and Occupational Functioning Scale (SOFAS). The DUP was defined as the time between the first appearance of psychotic symptoms and commencement of adequate antipsychotic treatment. Subjects were divided into two groups by the 3-month median DUP cutoff.

RESULTS

The average and median DUPs were 12 and 3 months, respectively. A longer DUP was associated with older age, a higher PANSS score, and a lower SOFAS score. The frequency of suicide attempts tended to be higher in the delayed treatment group (P = .055). The delayed treatment group scored significantly higher in conscientiousness factor of the BFI-10 and scored significantly lower family cohesion and adaptability factors of the FACES-III. Logistic regression showed that a longer DUP was significantly associated with higher-level conscientiousness on the BFI-10 and poorer family cohesion on the FACES-III.

CONCLUSION

Treatment delay was associated with reduced family cohesion and higher patient conscientiousness, suggesting that the family plays a crucial role in terms of patient access to mental health services when early psychotic symptoms appear.

Relationship between stressful life events, stigma and life satisfaction with the willingness of disclosure of psychotic illness: A community study in Hong Kong

AIM

The preference of and potential barriers to disclosure of psychotic illness vary across cultures. Studying its patterns and correlates can guide the design of future culture-specific intervention and public education approaches to improve willingness to disclose and thereby reducing the duration of untreated psychosis (DUP).

METHODS

A population-based, random telephone survey was conducted with a total of 1514 respondents in Hong Kong in January 2018. Cross-sectional data on willingness to disclose psychotic illness, life satisfaction, stigmatizing attitude and recent experience of stressful life events (SLEs) were analysed against age and gender using structural equation modelling (SEM).

RESULTS

Unwillingness to disclose to anyone was reported by 12% of the participants. Family was reported as the preferred disclosure candidate by most respondents. Our model, which showed a good fit to the data demonstrated that stigmatizing attitude and life satisfaction were directly associated with willingness to disclose illness. Younger age was correlated with more recent experience of SLEs, lower life satisfaction and less willingness to disclose illness. Women's disclosure willingness was positively associated with their life satisfaction, which was sensitive to recent exposure to single SLE. In contrast, men's was negatively associated with their stigmatizing attitude, which increased significantly upon exposure to two or more recent SLEs.

CONCLUSION

Encouraging the public to help their family to seek treatment should be a focal point of a successful mental health public education campaign. Cultural-specific and integrated interventions should be developed targeting the vulnerable groups including people with high recent life stress, particularly woman and those with younger age.

Stigma of mental illness and cultural factors in Pacific Rim region: a systematic review

BACKGROUND

Although cultural factors play a crucial role in experience of stigma, there is scant review on the impact and importance of culture on stigma of mental illness across Pacific Rim Region. This study aims to investigate: 1) the cultural factors related to stigmatizing beliefs about mental illness in Pacific Rim region, and 2) culture-specific measures and interventions on stigma of mental illness.

METHODS

A systematic search of papers was conducted in the MEDLINE, Embase, CINAHL, Web of Science, PsycINFO, Scopus, Cochrane Library and Google scholar through January 2003 to April 2019.

RESULTS

Forty-one studies in Pacific Rim region which met the inclusion criteria were included in the study. The rate of stigma of mental illness (e.g., public stigma: from 25.4 to 85.2%) was relatively high in Pacific Rim region. Culture factors (e.g., Collectivism, Confucianism, face concern and familism, religion and supernatural beliefs) contributed to people's stigmatizing behaviors and attitudes toward persons with mental illness, their relatives and mental health professionals. Certain measurements were developed and employed to assess different type of cultural factors related to stigma of mental illness.

CONCLUSIONS

Cultural factors play an important role in influencing the rate and performance of stigma of mental illness. Further research on stigma of mental illness and culture-specific interventions to reduce the stigma should be conducted in the Pacific Rim region.

Further Reduction in Help-Seeking Behaviors Amidst Additional Barriers to Mental Health Treatment in Asian Populations: A Contemporary Review

Under diagnosis and treatment of mental health illnesses lead to chronic presentations and consequences. Multiple factors contribute to gaps in treatment, including the role culture plays in the development or suppression of help-seeking behaviors (HSBs). In the Asian community, conversation and recognition of mental health and its disorders are considered shameful. This review presents an analysis of literature to identify barriers to mental health treatment pronounced in Asian populations and discusses how culture influences these barriers and treatment-seeking behaviors, particularly in the context of the Asian-origin Coronavirus disease 2019 (COVID-19) global pandemic. It is the purpose of this review to discuss Asian American underutilization of mental health services and understand the factors the contribute to psychiatric care resistance in Asian communities.

Utilization of Mental Health Services Among Older Chinese Immigrants in New York City

Older immigrants are at risk of developing mental illness. This study aims to examine mental health service utilization among older Chinese immigrants, using a mixed-method design. Andersen's Behavioral Model of Health Services Use informed an examination of predictors of mental health services utilization, and semi-structured individual interviews were conducted to illuminate these findings. Participants who were younger, had less than a high school education, and had a higher level of depressive symptoms were more likely to use mental health services. Stressors of psychological distress included breakdown of support system, language barriers, and financial hardships. Factors influencing mental health services use included information from family/friends, referrals from primary care physicians, perceived needs for help, mental health stigma, and culturally competent mental health professionals. Understanding the factors associated with seeking mental health services for older Chinese immigrants could help health care providers to develop early screening programs and culturally sensitive interventions.

A Review of Mental Health and Mental Health Care Disparities Research: 2011-2014

Racial/ethnic minorities in the United States are more likely than Whites to have severe and persistent mental disorders and less likely to access mental health care. This comprehensive review evaluates studies of mental health and mental health care disparities funded by the National Institute of Mental Health (NIMH) to provide a benchmark for the 2015 NIMH revised strategic plan. A total of 615 articles were categorized into five pathways underlying mental health care and three pathways underlying mental health disparities. Identified studies demonstrate that socioeconomic mechanisms and demographic moderators of disparities in mental health status and treatment are well described, as are treatment options that support diverse patient needs. In contrast, there is a need for studies that focus on community- and policy-level predictors of mental health care disparities, link discrimination- and trauma-induced neurobiological pathways to disparities in mental illness, assess the cost effectiveness of disparities reduction programs, and scale up culturally adapted interventions.

Disclosing psychiatric diagnosis to close others: a cultural framework based on older Latin@s participating in a depression trial in Los Angeles county

Objectives: The objective of this qualitative study is to explore disclosure of depression diagnosis to close others among older adult Latinas/Latinos (Latin@s) recruited from an urban health care system specializing in low-cost community health services in Los Angeles County. Method: Semi-structured in-depth interviews were conducted with 35 older Latinos who participated in an NIMH-funded randomized depression trial. Results: Psychiatric disclosure is a dynamic, multidimensional, and culturally ladened experience that entails weighing in on interrelated factors. This study presents a cultural framework of depression disclosure that highlights 15 facilitators and barriers which were organized into three intrinsic and relational domains: (a) individual emotional and support needs; (b) personal characteristics of the recipient of the disclosure; and (c) quality of the interpersonal interactions between the patient and recipient. Conclusion: Knowledge of Latin@ older adults' perspectives and experiences with depression disclosure can inform strategies to support older Latin@s facing the dilemma of disclosure.

An integrative model of internalized stigma and recovery-related outcomes among people diagnosed with schizophrenia in rural China

PURPOSE

Internalized stigma, an adverse psychological process, severely impedes the lives of people diagnosed with schizophrenia and restricts them from social integration and recovery. The aim of this study was to empirically evaluate an integrative model of relationship between internalized stigma and patients' recovery-related outcomes among people diagnosed with schizophrenia in a rural Chinese community.

METHOD

A total of 232 people diagnosed with schizophrenia in Xinjin, Chengdu, participated in this study and completed measures of internalized stigma, social interaction, perceived social support, social functioning, and symptoms. The internalized stigma of mental illness scale (ISMI) was used to measure the internalized stigma. Path analysis was used to test the association between internalized stigma and recovery-related outcomes.

RESULTS

There were no significant differences in mean scores of ISMI by gender, age (18-64 years and ≥ 65 years), education, marital status, or economic capacity. Internalized stigma was negatively associated with perceived social support and social interaction. Furthermore, higher level of internalized stigma was associated with impaired social functioning, and a lower level of social functioning was significantly associated with more severe symptoms.

CONCLUSION

Internalized stigma is associated with poor social interaction and weakened perceived social support in people diagnosed with schizophrenia, and is linked negatively to outcomes in their recovery. It is essential to tailor interventions related to reducing internalized stigma within a Chinese context and evaluate the effectiveness of anti-stigma intervention on recovery for people diagnosed with schizophrenia.

Exploring caregiving-related experiences among Chinese American and European American family caregivers of persons with mental illness

Family caregivers (FCs) of people with mental illness (PMI) experience caregiving-related distress. These challenges tend to be greater for Asian American families due to acculturative stress and structural barriers to services. However, little is known about caregiving-related experiences among FCs of PMI within a cultural context. By using an exploratory approach, we examined the experience of caregiver distress and the influence of cultural values on caregiving in European American and Chinese American FCs. In collaboration with community-based agencies, a combination of convenience and snowball sampling methods were used to recruit Chinese American and European American caregivers who co-reside with PMIs. Two focus groups with each ethnic group with 57 participants (30 Chinese and 27 European American) were conducted. Thematic analysis indicates that FCs experience intense emotions, health/mental health problems, and a negative impact on their personal/social lives. Whereas Chinese American FCs reported shame, lack of knowledge, and over-protectiveness of PMIs, European American FCs reported the need for advocacy on behalf of the PMI. Findings indicate a need for: 1) greater awareness of the caregiving experience on wellbeing of FCs; 2) an understanding of how cultural values may influence caregiver experience; and 3) developing culturally relevant prevention and intervention services that can support FCs from diverse cultural contexts.

Integrated mental health services in China: challenges and planning for the future

Eager to build an integrated community-based mental health system, in 2004 China started the '686 Programme', whose purpose was to integrate hospital and community services for patients with serious mental illness. In 2015, the National Mental Health Working Plan (2015-2020) proposed an ambitious strategy for implementing this project. The goal of this review is to assess potential opportunities for and barriers to successful implementation of a community-based mental health system that integrates hospital and community mental health services into the general healthcare system. We examine 7066 sources in both English and Chinese: the academic peer-reviewed literature, the grey literature on mental health policies, and documents from government and policymaking agencies. Although China has proposed a number of innovative programmes to address its mental health burden, several of these proposals have yet to be fully activated, particularly those that focus on integrated care. Integrating mental health services into China's general healthcare system holds great promise for increased access to and quality improvement in mental health services, as well as decreased stigma and more effective management of physical and mental health comorbidities. This article examines the challenges to integrating mental health services into China's general healthcare system, especially in the primary care sphere, including: accurately estimating mental health needs, integrating mental and physical healthcare, increasing workforce development and training, resolving interprofessional issues, financing and funding, developing an affordable and sustainable mental health system, and delivering care to specific subpopulations to meet the needs of China's diverse populace. As China's political commitment to expanding its mental health system is rapidly evolving, we offer suggestions for future directions in addressing China's mental health needs.

"My bitterness is deeper than the ocean": understanding internalized stigma from the perspectives of persons with schizophrenia and their family caregivers

Background

It is estimated that 8 million of the Chinese adult population had a diagnosis of schizophrenia. Stigma associated with mental illness, which is pervasive in the Chinese cultural context, impacts both persons with schizophrenia and their family caregivers. However, a review of the literature found a dearth of research that explored internalized stigma from the perspectives of both patients and their caregivers.

Methods

We integrated data from standardized scales and narratives from semi-structured interviews obtained from eight family-dyads. Interview narratives about stigma were analyzed using directed content analysis and compared with responses from Chinese versions of the Internalized Stigma of Mental Illness Scale and Affiliated Stigma Scale. Scores from the two scales and number of text fragments were compared to identify consistency of responses using the two methods. Profiles from three family-dyads were analyzed to highlight the interactive aspect of stigma in a dyadic relationship.

Results

Our analyses suggested that persons with schizophrenia and their caregivers both internalized negative valuation from their social networks and reduced engagement in the community. Participants with schizophrenia expressed a sense of shame and inferiority, spoke about being a burden to their family, and expressed self-disappointment as a result of having a psychiatric diagnosis. Caregivers expressed high level of emotional distress because of mental illness in the family. Family dyads varied in the extent that internalized stigma were experienced by patients and caregivers.

Conclusions

Family plays a central role in caring for persons with mental illness in China. Given the increasingly community-based nature of mental health services delivery, understanding internalized stigma as a family unit is important to guide the development of cultural-informed treatments. This pilot study provides a method that can be used to collect data that take into consideration the cultural nuances of Chinese societies.

Electronic supplementary material

The online version of this article (10.1186/s13033-018-0192-4) contains supplementary material, which is available to authorized users.

What is at stake? Exploring the moral experience of stigma with Indian-Australians and Anglo-Australians living with depression

This article applies the framework of moral experience to examine the cultural experience of stigma with Indian-Australians and Anglo-Australians living with depression in Melbourne, Australia. To date few studies have examined this dynamic in relation to mental illness and culture, and no studies have applied this framework in a culturally comparative way. Based on 58 in-depth interviews with people with depression recruited from the community, we explicate how stigma modulates what is at stake upon disclosure of depression, participants' lived experience following that disclosure, and how practices of health-seeking become stigmatised. Findings show that the social acceptance of depression jars against participants' experience of living with it. Denialism and fear of disclosure were overwhelming themes to emerge from our analysis with significant cultural differences; the Anglo-Australians disclosed their depression to family and friends and encountered significant resistance about the legitimacy of their illness. In contrast, many Indian-Australians, especially men, did not disclose their illness for fear of a damaged reputation and damaged social relations. For Indian-Australians, social relations in the community were at stake, whereas for Anglo-Australians workplace relations (but not community relations) were at stake. Participants' experiences in these settings also influenced their patterns of health-seeking behaviors and age and inter-generational relationships were important mediators of stigma and social support. These findings illuminate how stigma, culture, and setting are linked and they provide critical information necessary to identify and develop customised strategies to mitigate the harmful effects of stigma in particular cultural groups.

Psychometric Properties of the Inventory of Attitudes Toward Seeking Mental Health Services (Chinese Version)

ABSTRACTResearch on underutilization patterns of mental health services among older Chinese immigrants is limited, partly due to the absence of translated, psychometrically sound measures for assessing attitudes towards seeking help. In this study we interviewed 200 older Chinese Canadian immigrants using a translated version of the Inventory of Attitudes Toward Seeking Mental Health Services scale (IASMHS), and assessed mental health care utilization over the past 12 months and intentions to seek help. Confirmatory factor analysis failed to replicate the original three-factor structure; thus, we used exploratory factor analysis to create a 20-item Chinese version, the C-IASMHS. It had acceptable internal consistency and was positively correlated with intentions to seek help. The Help-Seeking Propensity subscale had the strongest psychometric properties whereas the Psychological Openness subscale performed poorly based on factor analysis results and unacceptable internal consistency. Future research should focus on the conceptual equivalence of psychological openness among Chinese older adults.

A qualitative study of immigrant women on long-term sick leave and their experience of dignity

PURPOSE

The purpose of this study was to explore if and how immigrant women suffering from chronic pain experience and maintain their dignity, during rehabilitation.

METHODS

The study was designed as a field study, with participant observation and in-depth interviews. Participant observations were carried out during a rehabilitation course for 14 immigrant women on an outpatient clinic at a rehabilitation hospital in southern Norway. In-depth interviews were performed after the rehabilitation period. Hermeneutic analysis was applied to interpret the data.

RESULTS

Findings show that the immigrant women experienced dignity by being seen, respected and believed by family-members, healthcare personnel and other patients at the outpatient clinic. Moreover, they maintained their dignity through a sense of their own value, integrity, religious faith and hope for the future.

CONCLUSIONS

The immigrant women maintained and protected their dignity by finding strength, pride, and self-worth in their religion and through their family-members' affection. Taking responsibility for themselves and others and experiencing fellowship and equality with other women, they enhanced their dignity during their rehabilitation process. The caring attitudes and behavior of some healthcare personnel promoted patient dignity. They also gained hope and dignity by experiencing goodness, cultural competence, and sensitivity from healthcare personnel. Implications for rehabilitation This study shows that the family role is more important for the immigrant women than the role as an employee, although financial independence and being able to help relatives financially also were central. Fellowship and equality with other patients, together with a rehabilitation program, which is facilitated for different language levels, were understood as important factors for an effective recovery. Enough time to get to know the patients and cultural competence seems to be central components for the health care personnel to give efficient help to immigrants in rehabilitation. Immigrants from low/middle-income countries appear to apply their religiousness as a resource in their lives to a greater extent than native Norwegians do, and should be taken into consideration when planning and implementing rehabilitation programs for immigrants.

Experiences of Social Support Among Chinese Immigrant Mental Health Consumers with Psychosis

Limited research has investigated how culture impacts expressions of social support, which is crucial in developing culturally sensitive care. Using a classification based on theories of social support, we examined the social support experiences of 49 Chinese immigrant mental health consumers with psychosis, paying particular attention to frequency and sources. We found that the most common forms of social support were belonging and companionship, perceived emotional support, social control, and perceived instrumental support, while self-esteem and sense of mastery were the least common forms. Family and friends were the main sources of support. These results demonstrate the influence of Confucian values of renqing (or fulfillment of relational obligations) and guanxi (or social networks) and the negative effects of stigma in diminishing the social standing of these consumers by compromising 'personhood.' Clinical implications for increasing the cultural competency of clinicians and improving the mental health outcomes of Chinese immigrants are discussed.

Culture- and Immigration-Related Stress Faced by Chinese American Families with a Patient Having Schizophrenia

The impact of culture and immigration on the experience of Chinese American families with a member having schizophrenia is explored within the frameworks of family systems and stress and coping. This qualitative study was conducted within an intervention study of family psychoeducation using therapists' session notes from 103 family sessions and 13 relatives' group sessions from nine patients and 19 relatives. The high stigma attached to mental illness leading to social isolation, and families' devotion to caregiving exacerbated caregiver burden. Taboo against discussing dating and sexuality and the consideration of arranged marriages caused unique stress. The insecurity as immigrants and shortage of bilingual services were related to greater enmeshment within these families. Implications on research methodology and practice are discussed.

Association between recognizing dementia as a mental illness and dementia knowledge among elderly Chinese Americans

AIM: To investigate whether older Chinese Americans perceive dementia as a mental illness and the relationship between such perception and their general understanding of dementia remains unclear. Our study aims to understand this relationship and its future implication on improving dementia literacy among ethnic minorities.

METHODS: Elderly Chinese American participants from the Greater Los Angeles were asked to complete an 11-item dementia questionnaire, following a community health seminar. Cross-sectional survey data was analyzed using standard statistical methods.

RESULTS: The questionnaire received an 88.3% response rate. Among 316 responders, only 28.8% (n = 91) of elderly Chinese Americans identified dementia as a mental illness, and 71.2% (n = 225) did not recognize its mental disease origin. Furthermore, in comparison between these two groups, the first group demonstrated significantly higher level of baseline knowledge of the disease.

CONCLUSION: This study reveals that only approximately 1 out of 4 older Chinese Americans recognized dementia as a mental illness, consistent with previous studies on Asian Americans. Our study however showed that when dementia was being perceived as a mental illness, such perception was associated with a higher level of baseline dementia understanding. The current study suggested the potential of improving older Chinese Americans dementia literacy by increasing awareness of its mental illness origin.

Influences of attribution and stigma on working relationships with providers practicing Western psychiatry in the Taiwanese context

This study examined influences of causal attributions of schizophrenia and perceived and internalized mental illness stigma on perceived working alliance with, and informational support received from doctors practicing Western psychiatry in the Taiwanese social-cultural context. This cross-sectional quantitative study used a non-probability, purposive sampling technique to recruit 212 Taiwanese diagnosed with schizophrenia from Taiwanese Alliance of the Mentally Ill, 4 community mental health rehabilitation centres and 2 psychiatric hospitals between July 2012 and March 2013. Linear regression models were used for analysis. The results showed that environmental attributions were positively associated with both perceived working alliance and perceived informational support, while supernatural attributions were negatively associated with perceived working alliance and perceived informational support. Perceived stigma had a negative association with perceived working alliance. The discrimination domain of internalized stigma specifically had a positive association with perceived working alliance, while the withdraw domain had a negative association with perceived informational support. Findings inform the importance of culturally sensitive practices in developing an effective working relationship. Western psychiatric care providers need to explore consumers' casual attributions of mental illness and understand the impact of stigma so that providers may successfully engage consumers in care and provide tailored illness education and information.