Mental illness stigma after a decade of Time to Change England: inequalities as targets for further improvement

Changes in the ability to correctly identify schizophrenia and depression: results from general population surveys in Germany over 30 years

PURPOSE

This study aims to examine time trends in the ability to correctly identify schizophrenia and major depression within the German general population from 1990 to 2020, as an indicator of changing mental health literacy (MHL). Additionally, we investigated shifts in the use of stigmatizing language.

METHODS

Our analysis is based on four waves of representative population surveys in Germany in 1990/1993 (West Germany: N = 2044, East Germany: N = 1563), 2001 (N = 5025), 2011 (N = 2455), and 2020 (N = 3042) using identical methodology. Respondents were presented with an unlabelled case vignette describing a person who exhibited symptoms of either schizophrenia or major depression. Participants were then asked to name the problem described in the vignette using an open-ended question.

RESULTS

From 1990/1993 to 2020, correct identification of schizophrenia increased from 18% to 34% and from 27% to 46% for major depression. However, derogatory labels remained constant throughout all survey waves, particularly for schizophrenia (19% in 1990/1993 and 18% in 2020). For depression, more trivializing and potentially devaluing statements were recorded.

CONCLUSION

Despite the increasing use of psychiatric terminology among the general population, the persistence of derogatory labels suggests that improved MHL, reflected in higher recognition rates, may not automatically translate into a reduction in stigmatizing language. With depression, a normalization and trivialization of a severe illness could pose new challenges to people with major depression. Dedicated efforts to combat the stigma of severe mental illness are still needed.

Snapshot of knowledge and stigma toward mental health disorders and treatment in Spain

Background

Mental disorders significantly impact individuals and societies globally. Addressing societal stigma is crucial, as it affects help-seeking behaviors and the effectiveness of treatment for mental disorders.

Objective

This study aims to explore the knowledge and perceptions of the Spanish population toward mental disorders and their treatment, assess changes in mental health stigma over time, and examine variations across sociodemographic variables by comparing current results with previous studies.

Methods

A panel of three psychiatrists designed a questionnaire to collect public opinions about various aspects of mental illness in Spain, covering topics such as social perception, diagnostic reliability, causes, symptoms, treatment, suicide, and media influence. The survey, conducted from October to December 2022, involved 1,002 Spanish individuals aged 18-70.

Results

Our results indicated an improved general knowledge of mental health, reduced stigma, and greater acceptance of those affected by these disorders, compared to past research. Almost 80% of the participants have accurate knowledge regarding the complex and multifactorial nature of mental illnesses. Around 90% of the participants share the belief that stigma affects those affected by mental disorders. Psychological and pharmacological treatment are considered to be effective and helpful by more than 70% of the sample. More than 60% of the participants highlighted that suicide needs to be addressed appropriately in the media.

Conclusion

These findings suggest a significant shift in how Spanish society views mental disorders, marking progress over decades of discrimination. Reducing the stigma associated with mental health can encourage individuals to seek assistance without the fear of judgment or discrimination, thereby increasing the likelihood of early intervention and treatment. Open conversations about mental health within families, communities, and workplaces can create a supportive environment that enhances recovery. However, continued efforts and awareness campaigns targeted to broader audiences remain necessary. Responsible media portrayals of mental health, avoiding stigmatizing language or sensationalism, are also essential.

Understanding the public stigma of mental illness: a mixed-methods, multi-level, exploratory triangulation study

BACKGROUND

This study examines the role of themata in understanding mental health-related stigma. It is motivated by the need for alternative theoretical-methodological approaches beyond the dominant frameworks in education and contact-based anti-stigma public health efforts, which have shown mixed effects. Specifically, it addresses the need for a more nuanced framework in stigma research, one that is sensitive to the dialogues through which people relate themselves to mental health and stigma in context.

METHODS

The research employs an exploratory mixed-methods approach, including the analysis of 529 news reports, 20 focus group discussions, and 19 one-to-one interviews, all concerning representations of shared living arrangements with someone perceived to have experiences of mental illness. Thematic analysis and natural language processing are used within a convergent triangulation design to analyze the data.

RESULTS

We found that mental health and illness were communicated through an overarching Self/Other thema and five subordinate themata: normal/abnormal, harm/non-harm, bounded/non-bounded, and moral/immoral. Despite familiarity with psychological distress and 'modern' explanations of mental illness, concerns about social identity motivated representations of mental illness as a predominantly permanent, negative form of personhood marked by abnormality, harm, distance, and immorality. Additionally, concerns about personal vulnerability, including historically rooted fears of contagion, motivated distancing representations of mental illness, rather than neutral portrayals.

CONCLUSIONS

Themata have under-developed theoretical and methodological potential for addressing mental health-related stigma, particularly in their ability to describe the dynamic ways in which culture motivates people to both resist and reproduce stigma, partly through ambivalences, absences, tensions, and ambiguities in representation. A critical discussion is provided on how themata may support ecological strategies in mental health campaigns over generic models, emphasizing the need to understand group knowledge and contact dynamics to mitigate adverse effects. Themata Public Health Unintended Consequences Mixed Methods Behaviour Change Natural Language Processing.

The Cost of Dying Exhibition: public, professional and political reactions to a visual exhibition depicting experiences of poverty at the end of life

Public health approaches to palliative care are internationally endorsed for their potential to improve the social determinants of dying such as energy costs, transport and housing. Enhancing public understanding of inequities in end of life experiences, which exist even in economically advanced countries, is vital if the value of public health approaches are to be endorsed and invested in. Visual exhibitions have a strong tradition of raising awareness and influencing public health discourse. The UK-based Cost of Dying exhibition (April-August 2023) presented real examples of how financial hardship and deprivation intersect with end of life experience through professional portraits, photovoice imagery taken by individuals at the end of their lives, and digital stories co-produced with bereaved relatives. Three iterations of the exhibition were displayed at public venues and a health conference. Evaluation methods comprised anonymous feedback cards (n=208), panel discussions and social media reactions. Thematic analysis was used to identify themes within the feedback. The emotional resonance of the exhibition was a key theme, with attendees expressing sadness, anger, empathy and hope. Visitors found the exhibition thought-provoking and expressed that it countered existing stereotypes about what it means to experience financial hardship at the end of life. The exhibition spurred calls for change, with some attendees questioning in what capacity they could help. Individuals with expertise in end of life care reported that the imagery validated their professional experiences. In conclusion, the Cost of Dying exhibition made visible the struggles endured by individuals confronting financial hardship and material deprivation at the end of life. Such exhibitions can challenge the traditional view of dying as a swift process taking place sequestered in institutions, revealing that it often unfolds over time and individuals may continue to live at home in the community, struggling with unmet needs and unresponsive state services.

'No health without mental health': where are we now?

Mental health services are under unprecedented pressure with overwhelming referrals and a current waiting list of 1.2 million people of all ages. The cross-government White Paper 'No health without mental health' was launched 12 years ago detailing the importance of wellbeing services in the creation of mentally healthy communities through health promotion and illness prevention. While primary care, community services and psychiatry are pivotal in the treatment of mental Illness/disorder, mental health care per se is on a continuum, and a great deal of work can be undertaken in communities by wellbeing services to prevent avoidable referrals. This paper proposes a broad framework of education and training for wellbeing/positive mental health services, primary and community care, and nurses working in Community Mental Health Treatment Teams and Home Treatment Teams to ensure all those working with potentially vulnerable adults and children are regulated and meet national standards for mandatory mental health education and training.

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.

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.

The Impact of Mental Illness and Intellectual Disability Information on General Public Perceptions of a Person Convicted of a Child Sex Offence

A person convicted of sex offences (PCSO) is confronted with several challenges upon re-entry to the community, often facing difficulties accessing housing and employment, and experiencing stigmatisation, hostility and harassment from community members. Given the importance of community support for successful reintegration, we examined differences in public (N = 117) attitudes toward a PCSO against a child (PCSO-C) with mental illness or intellectual disability compared to a neurotypical PCSO-C in an online survey. At present, differences in attitudes towards these groups has not been explored. Results indicated the PCSO-Cs with intellectual disability or mental illness were seen to pose less risk of sexual reoffending and prompted higher levels of reintegration comfort than the neurotypical PCSO-C. Participants' prior personal exposure to mental illness or intellectual disability was unrelated to attitudes, but those who believed that PCSOs in general have a low capacity for change attributed greater risk of sexual reoffending, greater risk of future harm to children, higher levels of blame and lower reintegration comfort, regardless of MI and ID information. Female participants also perceived greater risk of future harm to adults, and older participants estimated higher risk of sexual reoffending than younger participants. Findings have implications for community acceptance of PCSO-Cs and jury decision-making processes and highlight the importance of public education regarding neurodiverse PCSO-Cs and PCSO capacity for change to encourage knowledge-based judgements.

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

Are efforts to recruit to psychiatry closing the stable door after the horse has bolted? Knowledge and attitudes towards a career in psychiatry amongst secondary (high) school students: a UK-based cross-sectional survey

BACKGROUND

Internationally there is a shortage of psychiatrists, whilst clinical psychology training is generally oversubscribed. School students interested in psychological health may not be aware of the possibility of studying medicine before specialising in psychiatry. This has implications for the mental health workforce.

AIMS

To evaluate the knowledge and attitudes relating to a potential career in psychiatry amongst secondary (high) school students.

METHOD

A cross-sectional survey evaluated attitudes and knowledge relating to psychiatry and clinical psychology, targeting students from five schools who were studying chemistry, biology and/or psychology at an advanced level.

RESULTS

186 students completed the survey (response rate 41%). Knowledge was generally poor with only 57% of respondents knowing that psychiatrists had medical degrees, and most participants substantially underestimating the salaries of consultant psychiatrists. Attitudinal response patterns were explained by two underlying factors, relating to generally negative attitudes towards psychiatry and positive attitudes towards the effectiveness of psychiatric treatments. Females and those studying psychology reported more positive attitudes towards psychiatry. Those studying chemistry reported more negative attitudes towards the effectiveness of mental health treatment.

CONCLUSIONS

Studying psychology predicted positive attitudes towards psychiatry. Such students could be targeted by recruitment campaigns, which emphasise factual information about the specialty.

Medical student perceptions of mental illness: a cross-sectional transnational study in two medical schools

BACKGROUND

Despite shifting global attitudes, mental illness remains highly stigmatised amongst practicing doctors. This has wider implications on doctors' training to care for patients with mental illness. There is need for exploration of the presence and mitigation of stigma in early medical education to prevent such attitudes propagating into clinical practice. Thus, this study explores whether stigmatising attitudes are detectable amongst medical students in London and Singapore and examines whether they are ameliorated by specific curricular and welfare features of formal medical education, utilising the Mental Illness Stigma Framework (MISF).

METHODS

A mixed-methods approach was adopted. Medical students at Imperial College London (UK; n = 211) and Nanyang Technological University (Singapore; n = 141) completed a validated scale (the OMS-HC-15) to assess attitudes towards mental illness. Semi-structured interviews were conducted (Imperial: n = 12, NTU: n = 8) until theoretical saturation was reached. Quantitative data were analysed descriptively and comparatively using SPSS and interview data subjected to inductive thematic analysis.

RESULTS

Total OMS-HC-15 scores ranged from 19-51 for Imperial (n = 211) and 16-53 for NTU (n = 141). No significant differences in overall stigma scores were found between the two schools (p = 0.24), nor when comparing year groups within each school. Four themes were identified across interview data: student perceptions, impacts of medical school culture, university support, and curricular impacts on mental illness perceptions. Themes allowed identification of aspects of medical school that were well-received and warranted further emphasis by students, alongside areas for improvement.

CONCLUSION

Mental health stigma was identified in two medical schools, with differing cultures. Mean stigma scores obtained were comparable between both UK and Singaporean medical students. Nuanced differences were identified via subgroup analysis, and the MISF identified both shared and country-specific drivers for this stigma across the qualitative data. Actionable recommendations to mitigate this were hypothesised. Curricular improvements such as earlier psychiatric teaching and sharing of personal stories may improve future stigma scores as students' progress through the course. Specific welfare-based changes to formal support systems were also deemed to be beneficial by students. The impacts of welfare and curricular redesign in relation to societal influence on students' attitudes warrants further investigation, as does medical students' self-stigma.

The stigma of mental health problems: A cross-sectional study in a representative sample of Spain

BACKGROUND

Mental health stigma is a relevant phenomenon with implications for the people who suffer from it. Despite its importance, no studies have been carried out in Spain at national level with a representative sample of the population.

AIMS

The aim of this research is to analyze the stigma associated with MHPs in a representative sample of the Spanish population for the first time.

METHOD

A cross-sectional quantitative descriptive study was carried out with a representative sample of the population (N = 2746). Descriptive analyses and regressions are carried out on the different dimensions of stigma such as attitude, attribution and intention of social distance.

RESULTS

Medium levels of stigma are obtained in stigmatizing attitudes and attributions, and medium-low levels in the intention of social distance. The best predictors of stigma in its different dimensions are attitudes, attributions and intention of social distance themselves. Progressive political ideology is related to less stigma in all dimensions. Knowing someone with mental health problems and talking openly about it together with higher education are also relevant protectors. Mixed results are obtained regarding age, gender and help-seeking.

CONCLUSION

National programs and campaigns focused on attitudes, attributions and behavioral intentions are necessary to reduce the stigma still present in Spanish society.

Mental illness and help-seeking behaviours among Middle Eastern cultures: A systematic review and meta-synthesis of qualitative data

BACKGROUND

Western literature has long explored help-seeking behaviours related to mental health issues. However, this has been relatively neglected in the Middle East despite an increase in mental health needs in the region. The purpose of this review was to conduct a systematic review and qualitative meta-synthesis exploring help-seeking behaviours related to mental health issues in the Middle East.

METHODS

We conducted a systematic review and meta-synthesis to gain a comprehensive overview of what is known about mental health and help-seeking behaviours in the Middle East from published qualitative research in the Middle Eastern region. A search of electronic databases (MEDLINE, Embase, CINAHL, PsycINFO and QScience) was carried out from inception to July 2022. The quality of the included studies was assessed using the Critical Appraisal Skills Programme tool, and the review protocol was pre-registered with PROSPERO (Ref: CRD42022311494).

RESULTS

We identified 16 qualitative studies exploring mental health-seeking behaviours in Middle East countries. Facilitators and barriers to help-seeking were captured under six overarching themes. Across all studies, we identified negative attitudes towards seeking help for mental health issues, economic and structural barriers to accessing mental healthcare, and misconceptions surrounding religious beliefs, all of which had a critical role in impacting decisions to seek mental healthcare services. Many sought help from alternative sources, such as traditional healers or family members before consulting a healthcare professional. The role of the family and cultural norms was also identified as key contributors to people's help-seeking behaviours.

CONCLUSIONS

This meta-synthesis indicates the existence of many challenges surrounding mental health-seeking in the Middle East, including public and internalizing stigmas. This suggests an urgent need for an increase in psychoeducation and mental health awareness in the region.

Mental health related stigma in Romania: systematic review and narrative synthesis

BACKGROUND

Stigma related to mental illness is increasingly and more effectively addressed. Although more research is being conducted, there is relatively little from low and middle-income countries, with former Soviet bloc countries identified as a particular contributor to this evidence gap. Romania struggles with mental health stigma at many levels. The aim of this review was to bring together all relevant data regarding stigma and discrimination related to mental illness as well as actions to address these problems in Romania in order to prioritise further stigma research and identify priority targets for stigma reduction.

METHODS

A systematic literature search was conducted in three online databases and grey literature. After the analysis of full manuscripts, four were excluded based on lack of relevance or incomplete data reporting. Quality assessment was performed for included studies using the Mixed Methods Appraisal Tool (MMAT) and the narrative was synthesized based on the research questions.

RESULTS

The review included fifteen studies, the majority having a cross-sectional design. Stigma related to mental illness in Romania, has an impact on help-seeking attitudes and behaviours, workplace environment and social relationships of people with mental health problems. Negative stereotypes are maintained and validated by mass media reports. Significant stigma in healthcare and mental care settings has also been observed. Self-stigma was less frequently reported than public stigma. Despite a few stigma reduction actions, no rigorous evaluation of content, delivery and effectiveness has been conducted and no empirical evidence has been published.

CONCLUSIONS

Based on this review, three lines of action are recommended in Romania. Increase research concerning stigma in healthcare and mental care settings and use behavioural outcomes. Develop and deliver evidence-based tailored interventions to reduce stigma in identified priority subgroups of the population and ensure rigorous evaluation and scientific dissemination. Elaborate guidelines for working with community stigma and advocate for structural changes.

The effect of survey administration mode on youth mental health measures: Social desirability bias and sensitive questions

Aim

Research on trends in youth mental health is used to inform government policy and service funding decisions. It often uses interviewer-administered surveys, which may be affected by mode effects related to social desirability bias. This study sought to determine the impact of survey administration mode on mental health measures, comparing mode effects for sensitive mental health measures (psychological distress and wellbeing) and non-sensitive (physical activity) measures.

Methods

Data were from two large national community samples of young Australians aged 12-25 years conducted in 2020 (N = 6238) and 2022 (N = 4122), which used both interviewer-administered and self-report modes of data collection.

Results

Results showed participants reported lower psychological distress and higher wellbeing in the interviewer-assisted compared with the self-report mode. No mode effects were found for the non-sensitive physical activity measures. No interaction between mode and gender was found, but an age group by mode interaction revealed that those in the 18-21 and 22-25-year age groups were more strongly affected than younger adolescents.

Conclusions

These findings suggest underestimates of mental health issues from interview survey formats, particularly for young adults. The results show how even a weak mode effect can have a large impact on mental health prevalence indicators. Researchers and policy makers need to be aware of the impact social desirability bias can have on mental health measures and consider taking steps to mitigate this effect.

Suicide after leaving the UK Armed Forces 1996-2018: A cohort study

BACKGROUND

There are comparatively few international studies investigating suicide in military veterans and no recent UK-wide studies. This is important because the wider context of being a UK Armed Forces (UKAF) veteran has changed in recent years following a period of intensive operations. We aimed to investigate the rate, timing, and risk factors for suicide in personnel who left the UKAF over a 23-year period.

METHODS AND FINDINGS

We carried out a retrospective cohort study of suicide in personnel who left the regular UKAF between 1996 and 2018 linking national databases of discharged personnel and suicide deaths, using survival analysis to examine the risk of suicide in veterans compared to the general population and conditional logistic regression to investigate factors most strongly associated with suicide after discharge. The 458,058 individuals who left the UKAF accumulated over 5,852,100 person years at risk, with a median length of follow-up of 13 years, were mostly male (91%), and had a median age of 26 years at discharge. 1,086 (0.2%) died by suicide. The overall rate of suicide in veterans was slightly lower than the general population (standardised mortality ratio, SMR [95% confidence interval, CI] 94 [88 to 99]). However, suicide risk was 2 to 3 times higher in male and female veterans aged under 25 years than in the same age groups in the general population (age-specific mortality ratios ranging from 160 to 409). Male veterans aged 35 years and older were at reduced risk of suicide (age-specific mortality ratios 47 to 80). Male sex, Army service, discharge between the ages of 16 and 34 years, being untrained on discharge, and length of service under 10 years were associated with higher suicide risk. Factors associated with reduced risk included being married, a higher rank, and deployment on combat operations. The rate of contact with specialist NHS mental health services (273/1,086, 25%) was lowest in the youngest age groups (10% for 16- to 19-year-olds; 23% for 20- to 24-year-olds). Study limitations include the fact that information on veterans was obtained from administrative databases and the role of pre-service vulnerabilities and other factors that may have influenced later suicide risk could not be explored. In addition, information on contact with support services was only available for veterans in contact with specialist NHS mental health services and not for those in contact with other health and social care services.

CONCLUSIONS

In this study, we found suicide risk in personnel leaving the UKAF was not high but there are important differences according to age, with higher risk in young men and women. We found a number of factors which elevated the risk of suicide but deployment was associated with lower risk. The focus should be on improving and maintaining access to mental health care and social support for young service leavers, as well as implementing general suicide prevention measures for all veterans regardless of age.

"Coming out of the closet about sexual assault": Intersectional sexual assault stigma and (non) disclosure to formal support providers among survivors using Reddit

Sexual assault is a pervasive, violent and often gendered crime that can result in significant negative consequences. Many sexual assault survivors consider disclosing to health and social care providers, therapists, and others who collectively fall under the banner of formal support, in order to access information, referrals, treatment and/or emotional support, however barriers to disclosure remain. This qualitative study is unique in its application of an intersectional sexual assault stigmatization framework to understand (non)disclosure to formal support providers among diverse sexual assault survivors. Through anonymous online narratives posted to the platform Reddit, survivors documented experiences of intersectional sexual assault stigma (perceived, internalized, anticipated, experienced) showing that they were not only stigmatized through negative gender stereotyping, but they were also marginalized through other structural inequities. The experience of multiple marginalization that arose from intersectional sexual assault stigma often impeded survivors in accessing and/or utilizing the formal support they wished for. The findings suggest that formal support providers could benefit from stigma reduction training related specifically to sexual assault survivors and that current models of stigma and discrimination training need to be expanded to include intersectional stigma. Further, the findings suggest that beyond training at an organizational level, a broader intervention aimed at reducing structural stigma and discrimination toward sexual assault survivors at a societal level appears warranted. Implications for future research related to the unique disclosure, health, and social care needs of diverse sexual assault survivors and support-seeking online alongside or in lieu of formal support are discussed.

Is the self-reporting of mental health problems sensitive to public stigma towards mental illness? A comparison of time trends across English regions (2009-19)

PURPOSE

The prevalence of mental health problems has rapidly increased over time. The extent to which this captures changes in self-reporting due to decreasing stigma is unclear. We explore this by comparing time trends in mental health and stigma-related indicators across English regions.

METHODS

We produced annual estimates of self-reported mental disorders (SRMDs) across waves of the Health Survey for England (2009-18, n = 78,226) and three stigma-related indicators (knowledge, attitudes, and intended behaviour) across waves of the Attitudes Towards Mental Illness survey (2009-19, n = 17,287). Differences in trends were tested across nine Government Office Regions using linear models, adjusting for age, sex, ethnicity, marital status, and social class.

RESULTS

In 2009, SRMDs did not vary by region (p = 0.916), whereas stigma-related indicators did (p < 0.001), with London having the highest level of stigma and the North East having lowest level of stigma. Between 2009 and 2018, the prevalence of SRMDs increased from 4.3 to 9.1%. SRMDs increased and stigma-related indicators improved at different rates across regions over time (SRMDs p = 0.024; stigma-related indicators p < 0.001). London reported the lowest increase in SRMDs (+ 0.3 percentage point per year) yet among the largest improvements in attitudes and intended behaviour across regions.

CONCLUSIONS

Improvements in attitudes towards mental illness did not mirror changes in self-reported mental health problems across English regions over the past decade. The findings do not support the argument that changes in public stigma, at least when defined at this regional scale, have been driving the increase in self-reported mental health indicators in recent years.

Perceived public stigma and perceived public exposure by persons living with bipolar disorder: A qualitative study

BACKGROUND

Stigma impact the lives of persons living with bipolar disorder.

AIM

The aim of this study was to explore how perceived public stigma is described by people living with bipolar disorder and examine the links between perceived public stigma and perceived public exposure.

METHOD

Face-to-face in-depth interviews were conducted in a purposive sample of euthymic people living with bipolar disorder recruited in a mood disorder ambulatory unit.

RESULTS

Thematic analysis of the transcript yielded five independent themes that were related to perceived public stigma. Perceived public stigma of bipolar disorder was modeled as comprising the three elements of public stigmas (stereotype, prejudice, and discrimination), with the addition of public exposure as a core component.

CONCLUSION

The representation of bipolar disorder in society via newspapers, films/TV series, conferences, and celebrity self-disclosures is considered to have multiple impacts. People living with bipolar disorder have also reported a perceived public stigma of bipolar disorder that has both specific features and characteristics of general mental illness.

'You get looked at like you're failing': A reflexive thematic analysis of experiences of mental health and wellbeing support for NHS staff

Staff in the National Health Service (NHS) are under considerable strain, exacerbated by the COVID-19 pandemic; whilst NHS Trusts provide a variety of health and wellbeing support services, there has been little research investigating staff perceptions of these services. We interviewed 48 healthcare workers from 18 NHS Trusts in England about their experiences of workplace health and wellbeing support during the pandemic. Reflexive thematic analysis identified that perceived stigma around help-seeking, and staffing shortages due to wider socio-political contexts such as austerity, were barriers to using support services. Visible, caring leadership at all levels (CEO to line managers), peer support, easily accessible services, and clear communication about support offers were enablers. Our evidence suggests Trusts should have active strategies to improve help-seeking, such as manager training and peer support facilitated by building in time for this during working hours, but this will require long-term strategic planning to address workforce shortages.

Understanding the Association Between Mental Health Knowledge and Mental Health Service Utilization Among Black Adults

Mental health knowledge limitations may contribute to the treatment gap among Black adults. We conducted an online cross-sectional study of Black adults in the United States (n = 262, aged 18-65 years) from diverse ethnic backgrounds (African-Americans, African immigrants, Afro-Caribbean immigrants). Gamma regression using generalized linear models was used to estimate the associations between mental health knowledge and willingness to seek help from mental health professionals. After adjusting for age, education and ethnicity, participants with higher specific knowledge about mental health (such as recognition of schizophrenia as a mental illness) were 26% more likely to report willingness to seek help from a mental health professional for personal and emotional problems (RR = 1.26, CI 1.12-1.41, p < 0.001). Knowledge building interventions (such as psychoeducation) that seek to increase specific knowledge (rather than general knowledge) may correlate more strongly with utilization of mental health services among Black adults.

Public's Attitudes Toward Mentally Ill Offenders in Greece

Mentally ill offenders constitute a vulnerable population group with unique characteristics, and have endured multiple public stigmatizations, which has not been sufficiently studied. The purpose of this study was to capture attitudes of the public toward mentally ill offenders in relation to their perceptions of mental illness in general, as well as their degree of familiarity with it. Our sample of 2059 people can be overall described as a men preponderance, married, with mean value age of 26 years, higher educational level, and medium or higher socio-economic status. Participants completed the ATMIO, CAMI, and Familiarity scales online. The total familiarity index value with mental illness was found to be 4.88, which counts as moderate to low. It was also concluded that women and those with a high educational level sustained more positive attitudes toward mentally ill offenders. However, negative stereotypes (with a mean value of 26.20), stigmatizing attitudes related to risk in the community (mean 16.10), and reduced responsibility for actions (mean 9.45) were recorded, while some (mean 16.50) showed compassion and emphasized on the mentally ill need of rehabilitation. The youngest people were the ones who recorded the most absolute and harsh attitudes. These findings validate the need of raising awareness and informing, especially, the young public about issues of mental health, including the need to oppose prejudices with everyday measures, which can be accessible to the new generation. Besides, we should extend research to various professional groups that come in contact with mentally ill offenders in order to collect data, which could contribute for intervening policies and formulating different sets of strategies for those people.

Bullying in trauma and orthopaedics: a survey of staff in orthopaedic departments in the UK

Background/aims

An orthopaedic department requires good teamwork and communication to function. This is undermined by bullying and harassment, which may affect the victim's health and career.

Methods

A 26-item questionnaire was sent to all delegates who registered for a free orthopaedic webinar teaching series via email and social media. This study includes the responses from all those who had worked in a UK orthopaedic department.

Results

There were 168 respondents from varying backgrounds; 17.9% had experienced bullying or harassment in their orthopaedic department, while 36.3% had witnessed it. Women and people from ethnic minority backgrounds suffered 10.2% and 6.9% higher rates of bullying than their male or white counterparts respectively.

Conclusions

The results demonstrate that despite attempts to reduce bullying in orthopaedics, it remains prevalent, and particularly affects women and those from ethnic minority backgrounds. Orthopaedic departments must adapt to reflect changes in society.

Creating a hierarchy of mental health stigma: testing the effect of psychiatric diagnosis on stigma

BACKGROUND

Levels of mental health stigma experienced can vary as a function of the presenting mental health problem (e.g. diagnosis and symptoms). However, these studies are limited because they exclusively use pairwise comparisons. A more comprehensive examination of diagnosis-specific stigma is needed.

AIMS

The aim of our study was to determine how levels of mental health stigma vary in relation to a number of psychiatric diagnoses, and identify what attributions predict levels of diagnosis-specific stigma.

METHOD

We conducted an online survey with members of the public. Participants were assessed in terms of how much stigma they had, and their attributions toward, nine different case vignettes, each describing a different mental health diagnosis.

RESULTS

We recruited 665 participants. After controlling for social desirability bias and key demographic variables, we found that mental health stigma varied in relation to psychiatric diagnosis. Schizophrenia and antisocial personality disorder were the most stigmatised diagnoses, and depression, generalised anxiety disorder and obsessive-compulsive disorder were the least stigmatised diagnoses. No single attribution predicted stigma across diagnoses, but fear was the most consistent predictor.

CONCLUSIONS

Assessing mental health stigma as a single concept masks significant between-diagnosis variability. Anti-stigma campaigns are likely to be most successful if they target fearful attributions.

An Intervention Framework for Addressing Stigma on College Campuses: Findings From a 3-Year-Long Intervention Program

ABSTRACT

The ongoing COVID-19 pandemic will only exacerbate the rising mental health concerns among college students. However, stigma toward such concerns continues to hinder mental health care utilization among the students, requiring urgent evidence that can help guide college campuses in implementing effective antistigma interventions. We propose and provide evidence for an intervention based on findings from a 3-year-long antistigma intervention that was implemented on a Southeastern college campus in the United States. Unique random samples of college students, totaling N = 1727 across 3 years, were recruited as participants. Each year, participants completed a preintervention and postintervention survey comprising of questions related to demographics, stigma, and mental health care knowledge. Findings indicate that the stakeholder-led intervention decreased personal stigma and increased mental health care knowledge among students who were exposed to the intervention. Further research is needed to assess feasibility and efficacy of the proposed intervention framework on other campuses.

Charting an Alternative Course for Mental Health-Related Anti-Stigma Social and Behaviour Change Programmes

Mental health-related anti-stigma strategies are premised on the assumption that stigma is sustained by the public's deficiencies in abstract professional knowledge. In this paper, we critically assess this proposition and suggest new directions for research. Our analysis draws on three data sets: news reports (N = 529); focus groups (N = 20); interviews (N = 19). In each social context, we explored representations of mental health and illness in relation to students' shared living arrangements, a key group indicated for mental health-related anti-stigma efforts. We analysed the data using term-frequency inverse-document frequency (TF-IDF) models. Possible meanings indicated by TF-IDF modelling were interpreted using deep qualitative readings of verbatim quotations, as is standard in corpus-based research approaches to health and illness. These results evidence the flawed basis of dominant mental health-related anti-stigma campaigns. In contrast to deficiency models, we found that the public made sense of mental health and illness using dynamic and static epistemologies and often referenced professionalised understandings. Furthermore, rather than holding knowledge in the abstract, we also found public understanding to be functional to the social context. In addition, rather than being agnostic about mental health-related knowledge, we found public understandings are motivated by group-based identity-related concerns. We will argue that we need to develop alternative anti-stigma strategies rooted in the public's multiple contextualised sense-making strategies and highlight the potential of engaging with ecological approaches to stigma.

Is it time to change the approach of mental health stigma campaigns? An experimental investigation of the effect of campaign wording on stigma and help-seeking intentions

Introduction

Mental health stigma causes a range of diverse and serious negative sequelae. Anti-stigma campaigns have largely aligned with medical theories and categorical approaches. Such campaigns have produced some improvements, but mental health stigma is still prevalent. The effect of alternative theoretical perspectives on mental health within anti-stigma campaigns has not been tested. Moreover, we do not know their effect on help-seeking intentions.

Methods

We conducted an online experimental pre-post study comparing the effects of two anti-stigma campaign posters on mental health stigma and help-seeking intentions. One poster adhered to the medical, categorical approach to mental health, whereas the other poster portrayed mental health problems in line with a non-categorical, continuous perspective.

Results

After controlling for familiarity with the campaign poster, country of residence and pre-test scores, we found no significant between-group differences in terms of help-seeking intentions and all stigma attitudes except for danger-related beliefs. That is, those who viewed the non-categorical poster reported an increased perception that people with mental health problems are dangerous.

Discussion

Our largely null findings may suggest the equivalence of these posters on stigma and help-seeking intentions but may also reflect the brevity of the intervention. Our findings concerning danger beliefs may reflect a Type I error, the complexities of stigma models, or the adverse effects of increased perceived contact. Further research is needed to test the effects of differing mental health paradigms on stigma and help-seeking intentions over a longer duration.

Public attitudes towards protecting the human rights of people with mental illness: a scoping review and data from a population trend study in Germany

The human rights of people with mental illness are constantly threatened. We conduct a scoping review showing how public attitudes towards protecting human rights have so far been examined and providing an overview of our present knowledge of these attitudes, and present novel findings from a trend study in Germany over nine years, reporting attitudes elicited in 2020 and examining whether these attitudes have changed since 2011. Few studies address attitudes towards human rights explicitly, but several studies contain single items on either first generation human rights, mainly concerning involuntary admission, or civil liberties like the right to vote, or second generation human rights, mainly with regard to funding for healthcare, but also for example regarding career choice. Recent data from Germany showed little improvement in attitudes towards protecting human rights over the last decade and particularly high support for restricting job opportunities for people with mental illness. Although generally, most restrictions were supported by a minority of respondents only, both our data and our scoping review indicate substantial support for several restrictions in several countries, showing that public attitudes pose a challenge to the human rights of persons with mental illness. We discuss possible lines of future research.

A myth-busting mental health tour of the National Gallery in London: facilitators and challenges to its development and evaluation

This paper describes a mental health-awareness audio tour of the National Gallery, London, and evaluates the development and implementation of the tour. This smartphone-based audio tour was co-produced by Gallery staff, young people with lived experience of mental health issues, academics, and technologists. Interviews (N = 22) were conducted with developers and data-collectors (who had gathered feedback from Gallery visitors who undertook the tour) with responses analysed thematically. Participants highlighted the value of the arts to raise awareness about mental health, and the importance of teamwork, lived experience, and co-production, but also raised the challenges of integrating low-budget projects into large-scale venues.

“I want you to help me, you’re family”: A relational approach to women's experience of distress and recovery in the perinatal period

Theoretical approaches have tended to understand perinatal distress through either individual or socio-cultural factors. In contrast, Natasha Mauthner proposed a relational model that understands perinatal distress in the context of interpersonal relationships. This study aims to build on Mauthner's work to explore how women speak about their relationships in connection to their stories of perinatal distress and recovery. Eight women were interviewed for the study. All women had at least one child under the age of three and self-identified as having experienced distress in the perinatal period. Interviews were recorded, transcribed and analyzed using Voice Centred Relational Analysis. Four broad themes were identified: (i) the role of practical support, (ii) the role of emotional support, (iii) relational dynamics, and (iv) the role of socio-cultural norms. Whilst some women experienced practical and emotional support in their relationships, those who did not linked a lack of support to their feelings of distress. Relationships were also found to reinforce unhelpful social norms around motherhood and mental health, as well as offering a space to resist norms and create wider discourses about what it means to be a mother. This study suggests that organizations supporting women in the perinatal period should focus on women's relational needs and consider the cultural discourses of motherhood that they perpetuate.

LGBTQ+ Psychosocial Concerns in Nursing and Midwifery Education Programmes: Qualitative Findings from a Mixed-Methods Study

LGBTQ+ people experience significant physical and psychosocial health issues and concerns, and encounter barriers when accessing healthcare services. We conducted a mixed-methods research study across all Schools of Nursing and Midwifery in the United Kingdom and Ireland using a survey and qualitative interviews. This was to identify the current content within nursing and midwifery pre-registration programmes in relation to LGBTQ+ health and to identity best practice and education innovation within these programmes. The survey was completed by 29 academics, with 12 selected to participate in a follow-up in-depth qualitative interview. Analysis of the data from the survey and interviews identified five themes: there is variable programme content; academics are developing their own programmes with no clear consistency; LGBTQ+ health is being linked to equality and diversity; there are barriers to education provision; and these is some evidence of best practice examples. The findings of the study support the need to develop and implement a curriculum for LGBTQ+ health in nursing and midwifery pre-registration programmes with learning aims and outcomes. Academics need support and tools to prepare and deliver LGBTQ+ health content to nurses and midwives as they ultimately have the potential to improve the experiences of LGBTQ+ people when accessing healthcare.

Experiences of people seen in an acute hospital setting by a liaison mental health service: responses from an online survey

Background

In recent years the UK has expanded the provision of liaison mental health services (LMHS). Little work has been undertaken to explore first-hand experiences of them.

Aims

The aim of this study was to gain insights into the experiences of users of LMHS in both emergency departments and acute inpatient wards in the UK.

Methods

This cross-sectional internet survey was initially advertised from May-July 2017 using the social media platform Facebook. Due to a paucity of male respondents, it was re-run from November 2017-February 2018, specifically targeting male respondents. The survey featured a structured questionnaire divided into three categories: the profile of the respondent, perceived professionalism of LMHS and overall opinion of the service.

Analysis

Responses to the structured questionnaire were analysed using descriptive statistics and latent class analysis. Free-text responses were transcribed verbatim and interpreted using thematic analysis.

Results

184 people responded to the survey. 147 were service users and 37 were partners, friends or family members of service users. Only 31% of service users and 27% of close others found their overall contact helpful. Latent class analysis identified three clusters − 46% of service users generally disliked their contact, 36% had an overall positive experience, and 18% did not answer most questions about helpfulness or usefulness. Features most frequently identified as important were the provision of a 24/7 service, assessment by a variety of healthcare professionals and national standardisation of services. Respondents indicated that the least important feature was the provision of a separate service for older people. They desired faster assessments following referral from the parent team, clearer communication about next steps and greater knowledge of local services and third sector organisations.

Conclusions

This survey identified mixed responses, but overall experiences were more negative than indicated in the limited previous research. The evaluation and adaptation of LMHS along the lines suggested in our survey should be prioritised to enhance their inherent therapeutic value and to improve engagement with treatment and future psychiatric care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06974-4.

The experiences of family caregivers of people with severe mental illness in the Middle East: A systematic review and meta-synthesis of qualitative data

BACKGROUND

There is a wealth of literature exploring the experiences of family caregivers of people with severe mental illness (SMI) in western countries, however, this topic has been neglected in the Middle East, despite families being the main source of caregiving in this context. The purpose of this review was to conduct a systematic review and qualitative meta-synthesis to explore the experiences of family caregivers living in countries in the Middle East caring for a relative with severe mental illness.

METHODS

A systematic review and meta-synthesis were conducted, to comprehensively gain a thorough and detailed overview of what is known about family caregivers' experiences from published qualitative research in the Middle East geographical area from inception to May 2021. The review protocol was pre-registered with PROSPERO (Ref: CRD42020165519).

RESULTS

The review identified twelve qualitative studies that explored caregivers' experiences of caring for relatives with SMI in Middle East countries. Family caregivers' experiences were captured under seven overarching themes. The participants across all studies reported negative consequences of providing care, increased burden and emotional distress. Many experienced issues with family/marital relationships and stigmatizing attitudes and behaviours from their communities. Caregivers expressed the need for increased support which was perceived to have a critical role in improving family caregivers' experiences.

CONCLUSIONS

The meta-synthesis revealed many challenges and issues that affect caregivers of people with SMI in the Middle East. Family caregivers experienced distress and burden, and reported significant impact on their psychological well-being. Their experiences highlight the urgent need to provide more support for family caregivers in Middle East countries.

Perceived need for treatment and non-utilization of outpatient psychotherapy in old age: two cohorts of a nationwide survey

BEACKGROUND

Older adults with mental health problems may benefit from psychotherapy; however, their perceived need for treatment in relation to rates of non-utilization of outpatient psychotherapy as well as the predisposing, enabling, and need factors proposed by Andersen's Model of Health Care Utilization that account for these differences warrant further investigation.

METHODS

We used two separate cohorts (2014 and 2019) of a weighted nationwide telephone survey in Germany of German-speaking adults with N = 12,197 participants. Across the two cohorts, 12.9% (weighted) reported a perceived need for treatment for mental health problems and were selected for further analyses. Logistic Generalized Estimation Equations (GEE) was applied to model the associations between disposing (age, gender, single habiting, rural residency, general health status), enabling (education, general practitioner visit) non-utilization of psychotherapy (outcome) across cohorts in those with a need for treatment (need factor).

RESULTS

In 2014, 11.8% of 6087 participants reported a perceived need for treatment due to mental health problems. In 2016, the prevalence increased significantly to 14.0% of 6110 participants. Of those who reported a perceived need for treatment, 36.4% in 2014 and 36.9%in 2019 did not see a psychotherapist - where rates of non-utilization of psychotherapy were vastly higher in the oldest age category (59.3/52.5%; 75+) than in the youngest (29.1/10.7%; aged 18-25). Concerning factors associated with non-utilization, multivariate findings indicated participation in the cohort of 2014 (OR 0.94), older age (55-64 OR 1.02, 65-74 OR 1.47, 75+ OR 4.76), male gender (OR 0.83), lower educational status (OR 0.84), rural residency (OR 1.38), single habiting (OR 1.37), and seeing a GP (OR 1.39) to be related with non-utilization of psychotherapy; general health status was not significantly associated with non-utilization when GP contact was included in the model.

CONCLUSION

There is a strong age effect in terms of non-utilization of outpatient psychotherapy. Individual characteristics of both healthcare professionals and patients and structural barriers may add to this picture. Effective strategies to increase psychotherapy rates in those older adults with unmet treatment needs are required.

Evaluation of anti-stigma social marketing campaigns in Ghana and Kenya: Time to Change Global

Background

Launched in 2018, Time to Change Global is a new anti-stigma programme to tackle stigma and discrimination towards people with mental health problems in low- and middle-income countries. Our aim was to evaluate pre-post changes in stigma within the target populations for the social marketing campaigns ran in Ghana and Kenya carried out as components of the wider Time to Change Global programme.

Methods

Using data collected before and after each campaign in Accra and Nairobi, we investigated pre-post differences in stigma-related outcome measures: mental health-related knowledge (MAKS), mental health-related attitudes (CAMI), and desire for social distance (RIBS), with regression analyses. Other covariates were included in the models to control for differences in participant demographics.

Results

A significant positive change in a stigma related outcome was found at each site. Reported in standard deviation units, desire for social distance from people with mental health problems in Accra was lower after the launch of the campaign, measured as an increase in intended contact (β = 0.29, 95% CI = 0.14 to 0.43, p < 0.001). In Nairobi, the stigma related knowledge score was higher in the post campaign sample (β = 0.21, 95% CI = 0.07 to 0.34, p = 0.003).

Conclusion

The increase in intended contact in the absence of other changes seen in Ghana, is consistent with the early results for Time to Change England. The estimate for the magnitude of this change is the same as Time to Change England for the general population between 2009 and 19, a very promising result for a short term public mental health campaign. The different results observed between sites may be due to campaign as well as population differences.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10966-8.

Review of Australian initiatives to reduce stigma towards people with complex mental illness: what exists and what works?

Background

Australian national mental health policy outlines the need for a nationally coordinated strategy to address stigma and discrimination, particularly towards people with complex mental illness that is poorly understood in the community. To inform implementation of this policy, this review aimed to identify and examine the effectiveness of existing Australian programs or initiatives that aim to reduce stigma and discrimination.

Method

Programs were identified via a search of academic databases and grey literature, and an online survey of key stakeholder organisations. Eligible programs aimed to reduce stigma towards people with complex mental illness, defined as schizophrenia, psychosis, personality disorder, or bipolar disorder; or they focused on nonspecific ‘mental illness’ but were conducted in settings relevant to individuals with the above diagnoses, or they included the above diagnoses in program content. Key relevant data from programs identified from the literature search and survey were extracted and synthesized descriptively.

Results

We identified 61 programs or initiatives currently available in Australia. These included face-to-face programs (n = 29), online resources (n = 19), awareness campaigns (n = 8), and advocacy work (n = 5). The primary target audiences for these initiatives were professionals (health or emergency), people with mental illness, family or carers of people with mental illness, and members of the general population. Most commonly, programs tended to focus on stigma towards people with non-specific mental illness rather than on particular diagnostic labels. Evidence for effectiveness was generally lacking. Face-to-face programs were the most well-evaluated, but only two used a randomised controlled trial design.

Conclusions

This study identified areas of strength and weakness in current Australian practice for the reduction of stigma towards people with complex mental illness. Most programs have significant input from people with lived experience, and programs involving education and contact with a person with mental illness are a particular strength. Nevertheless, best-practice programs are not widely implemented, and we identified few programs targeting stigma for people with mental illness and their families, or for culturally and linguistically diverse communities, Aboriginal and Torres Strait Islander communities and LGBTIQ people. These can inform stakeholder consultations on effective options for a national stigma and discrimination reduction strategy.

A Call to Action. A Critical Review of Mental Health Related Anti-stigma Campaigns

Using a knowledge-attitudes-behavior practice (KABP) paradigm, professionals have focused on educating the public in biomedical explanations of mental illness. Especially in high-income countries, it is now common for education-based campaigns to also include some form of social contact and to be tailored to key groups. However, and despite over 20 years of high-profile national campaigns (e.g., Time to Change in England; Beyond Blue in Australia), examinations suggest that the public continue to Other those with experiences of mental ill-health. Furthermore, evaluations of anti-stigma programs are found to have weak- to no significant long-term effects, and serious concerns have been raised over their possible unintended consequences. Accordingly, this article critically re-engages with the literature. We evidence that there have been systematic issues in problem conceptualization. Namely, the KABP paradigm does not respond to the multiple forms of knowledge embodied in every life, often outside conscious awareness. Furthermore, we highlight how a singular focus on addressing the public's perceived deficits in professionalized forms of knowledge has sustained public practices which divide between "us" and "them." In addition, we show that practitioners have not fully appreciated the social processes which Other individuals with experiences of mental illness, nor how these processes motivate the public to maintain distance from those perceived to embody this devalued form of social identity. Lastly, we suggest methodological tools which would allow public health professionals to fully explore these identity-related social processes. Whilst some readers may be frustrated by the lack of clear solutions provided in this paper, given the serious unintended consequences of anti-stigma campaigns, we caution against making simplified statements on how to correct public health campaigns. Instead, this review should be seen as a call to action. We hope that by fully exploring these processes, we can develop new interventions rooted in the ways the public make sense of mental health and illness.

Relationships between types of UK national newspapers, illness classification, and stigmatising coverage of mental disorders

BACKGROUND

Media coverage on mental health problems has been found to vary by newspaper type, and stigma disproportionately affects people with mental illness by diagnosis.

OBJECTIVE

This study investigated the relationships between types of UK national newspaper (tabloid vs. broadsheet), illness classification (SMI-severe mental illnesses vs. CMD-common mental disorders), and stigmatising coverage of mental disorders, and whether these relationships changed over the course of the Time to Change anti-stigma programmes in England and Wales.

METHODS

Secondary analysis of data from a study of UK newspaper coverage of mental illness was performed. Relevant articles from nine UK national newspapers in 2008-11, 2013, 2016 and 2019 were retrieved. A structured coding framework was used for content analysis. The odds an article was stigmatising in a tabloid compared to a broadsheet, and about SMI compared to CMD, were calculated. Coverage of CMD and SMI by newspaper type was compared using the content elements categorised as stigmatising or anti-stigmatising.

RESULTS

2719 articles were included for analysis. Articles in tabloids had 1.32 times higher odds of being stigmatising than articles in broadsheet newspapers (OR 1.32, 95% CI 1.12-1.55). Odds of stigmatising coverage was 1.72 times higher for articles on SMI than CMD (OR  1.72, 95% CI 1.39-2.13). Different patterns in reporting were observed when results were stratified by years for all analyses. A few significant associations were observed for the portrays of stigmatising elements between tabloid and broadsheet newspapers regarding SMI or CMD.

CONCLUSIONS

Tailored interventions are needed for editors and journalists of different newspaper types, to include specific strategies for different diagnoses.

Improvement for most, but not all: changes in newspaper coverage of mental illness from 2008 to 2019 in England

AIMS

Time to Change, an anti-stigma programme in England, has worked to reduce stigma relating to mental illness in many facets of life. Newspaper reports are an important factor in shaping public attitudes towards mental illnesses, as well as working as a barometer reflecting public opinion. This study aims to assess the way that coverage of mental health topics and different mental illnesses has changed since 2008.

METHOD

Articles covering mental health in 18 different newspapers were retrieved using keyword searches on two randomly chosen days of each month in 2008, 2009, 2010, 2011, 2013, 2014, 2016 and 2019. A content analysis approach using a structured coding framework was used to extract information from the articles. Logistic regression models were used to estimate the change in odds of each hypothesised stigmatising or anti-stigmatising element occurring in 2019 compared to 2008 and 2016 with a Wald test to assess the overall significance of year as a predictor in the model. Further logistic regression models were used to assess the association between the diagnosis that an article was about and the odds that it was stigmatising, and whether this relationship is moderated by year of publication.

RESULTS

A total of 6731 articles were analysed, and there was a significant increase in anti-stigmatising articles in 2019 compared to 2008 (OR 3.16 (2.60-3.84), p < 0.001) and 2016 (OR 1.40 (1.16-1.69), p < 0.001). Of the 5142 articles that specified a diagnosis, articles about schizophrenia were 6.37 times more likely to be stigmatising than articles about other diagnoses (OR 6.37 (3.05-13.29) p < 0.001), and there was evidence that the strength of this relationship significantly interacted with the year an article was published (p = 0.010). Articles about depression were significantly less likely to be stigmatising (OR 0.59 (0.69-0.85) p = 0.018) than those about other diagnoses, while there was no difference in coverage of eating disorders v. other diagnoses (OR 1.37 (0.67-2.80) p = 0.386); neither of these relationships showed an interaction with the year of publication.

CONCLUSION

Anti-stigma programmes should continue to work with newspapers to improve coverage of mental illness. However, interventions should consider providing specific guidance and promote awareness of rarer mental illnesses, such as schizophrenia, and evaluation should examine whether reductions in stigma extend to people with all mental illness diagnoses.

Moderation by socioeconomic status of the relationship between familiarity with mental illness and stigma outcomes

Purpose

Multiple studies suggest response to mental health treatment is worse for people of lower socioeconomic status, a group who also express more mental illness stigma. Worse response to treatment may lead to greater therapeutic pessimism, an important component of stigma. However, familiarity with mental illness is associated with lower levels of stigma. This study therefore examines whether, among the general public, socioeconomic status moderates the relationships between familiarity and stigma related outcomes: knowledge; attitudes; and desire for social distance.

Methods

We carried out secondary analysis of data from the Attitudes to Mental Illness survey, collected annually from different general population samples from 2009-17, and every two years from 2017-19. Three separate multiple linear regression models examined factors associated with each outcome, with interaction tests between socioeconomic status and familiarity. Stigma related knowledge was measured using the Mental Health Knowledge Schedule (MAKS), which includes items on treatment effectiveness and recovery, thus addressing aspects of therapeutic pessimism. Attitudes were measured using the Community Attitudes towards the Mentally Ill Scale; and desire for social distance using the Reported and Intended Behaviour scale.

Results

In lower socioeconomic groups, personal experience was more frequent, while familiarity with someone else was less frequent. Interaction tests were significant for stigma related knowledge (p<0.0001) and desire for social distance (p=0.0118), but not for attitudes (p=0.057). The direction of the interaction differed between knowledge and the other outcomes. In lower socioeconomic groups the positive effect of familiarity on knowledge was weaker, as hypothesised, but for attitudes and desire for social distance, its effect was stronger.

Conclusions

Our results support the promotion of familiarity through encouraging discussion of mental health problems within social networks. However, lower stigma related knowledge among people with personal experience in lower socioeconomic groups suggests different responses to mental illness among these groups are needed.

•

Familiarity with mental illness is associated with lower levels of stigma.

•

Different experiences of familiarity may lead to moderation by socioeconomic group.

•

The effect of familiarity on knowledge is weaker in lower socioeconomic groups.

•

The results suggest more therapeutic pessimism in lower socioeconomic groups.