Schizophrenia and the cultural epidemiology of stigma in Bangalore, India

A mediation analysis evaluating change in self-stigma on diabetes outcomes among people with depression in urban India: A secondary analysis from the INDEPENDENT trial of the collaborative care model

Self-stigma-the internalization of negative community attitudes and beliefs about a disease or condition-represents an important barrier to improving patient care outcomes for people living with common mental disorders and diabetes. Integrated behavioral healthcare interventions are recognized as evidence-based approaches to improve access to behavioral healthcare and for improving patient outcomes, including for those with comorbid diabetes, yet their impact on addressing self-stigma remains unclear. Using secondary data from the Integrating Depression and Diabetes Treatment (INDEPENDENT) study-a trial that aimed to improve diabetes outcomes for people with undertreated and comorbid depression in four urban Indian cities via the Collaborative Care Model-we longitudinally analyzed self-stigma scores and evaluated whether change in total self-stigma scores on diabetes outcomes is mediated by depressive symptom severity. Self-stigma scores did not differ longitudinally comparing Collaborative Care Model participants to enhanced standard-of-care participants (mean monthly rate of change in Self-Stigma Scale for Chronic Illness-4 Item scores; B = 0.0087; 95% CI: -0.0018, 0.019, P = .10). Decreases in total self-stigma scores over 12 months predicted diabetes outcomes at 12 months (HbA1c, total effect; B = 0.070 95%CI: 0.0032, 0.14; P < .05), however depressive symptoms did not mediate this relationship (average direct effect; B = 0.064; 95% CI: -0.0043, 0.13, P = .069). Considering the local and plural notions of stigma in India, further research is needed on culturally grounded approaches to measure and address stigma in India, and on the role of integrated care delivery models alongside multi-level stigma reduction interventions. Trial registration : ClinicalTrials.gov, NCT02022111. https://clinicaltrials.gov/study/NCT02022111.

Cross-cultural differences in depression between White British and South Asians: Causal attributions, stigma by association, discriminatory potential

OBJECTIVES

Numerous facets of public and internalized mental illness stigma have been established. This study focuses on the stigma of being associated with someone with depression and cultural differences between a Western and an Eastern culture. The aim was to compare White British and South Asians living in the United Kingdom regarding their causal explanations for depression, stigma towards people with depression and stigma by association.

DESIGN

A cross-sectional design.

METHODS

White British and South Asians (N = 137) in the United Kingdom completed a survey measuring attributions about the aetiology of depression, discriminatory potential towards people with depression and stigma by association.

RESULTS

Results revealed that South Asians attributed greater supernatural, moral and psychosocial causes to depression, while White British endorsed greater biological beliefs. South Asians reported a greater discriminatory potential towards people with depression (lower willingness for closeness, greater desire for social distance) than White British. They also indicated greater affective, cognitive and behavioural stigma by association. Stigma by association mediated the relationship between cultural group and willingness for closeness as well as desire for social distance. Perceived dangerousness was a mediator for willingness for closeness.

CONCLUSIONS

These findings suggest that a greater consideration of the role of culture in the understanding of mental health is important to combat stigma towards individuals with depression and those close to them across Western and Eastern cultures.

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

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

The cultural epidemiology of stigma among people with schizophrenia : Adaptation and cross-cultural validation of the Explanatory Model Interview Catalogue (EMIC), in Dialectal Arabic (Darija), Morocco

INTRODUCTION

Stigma underlies the violation of certain social, economic, and cultural rights of patients with schizophrenia, including their access to treatment and care. Measurement of stigma remains as complex and multifaceted as the phenomenon itself. Several measurement tools are available to assess the prevalence, intensity and qualities of stigma. The aim of the study was to carry out a cross-cultural adaptation of the Explanatory Model Interview Catalogue (EMIC), in the Moroccan Arabic dialect commonly known as "Darija".

PATIENTS AND METHOD

The study was conducted in three psychiatric departments of public hospitals in the Souss-Massa region, located in southern Morocco. For the diagnosis of schizophrenia, the study was based on the decisions of the psychiatrists practicing at the study sites. The cross-cultural adaptation in Moroccan Darija of the stigma scale developed by Michel Weiss in the EMIC was carried out according to the six-step scientific method developed by Dorcas et al.

RESULTS

Cronbach's alpha (internal consistency) was 0.845. Convergent validity determined by Pearson's coefficient showed a significant inter-item correlation and the intra-class correlation coefficient (test-retest) was 0.975 (0.993; 0.991). The item added in relation to the COVID-19 situation presented psychometric values similar to the others.

CONCLUSION

The Darija version is culturally acceptable and can be used to approach the phenomenon of stigmatization in Morocco.

Associations of Depression and Anxiety with Stigma in a Sample of Patients in Saudi Arabia Who Recovered from COVID-19

Purpose

The coronavirus disease (COVID-19) outbreak combined with social distancing, isolation, and movement restrictions has had a profound impact on individuals’ physical and psychological well-being. The aim of this study was to examine the associations of depression and anxiety with feelings of stigma among patients in Saudi Arabia who have recovered from COVID-19.

Materials and Methods

A cross-sectional survey was conducted between July and December 2020. Trained healthcare providers contacted and interviewed participants by phone. Depression, anxiety, and stigma were assessed using the Patient Health Questionnaire (PHQ-9), the Generalized Anxiety Disorder (GAD-7) questionnaire, and the Explanatory Model Interview Catalogue stigma scale (EMIC). Data on sociodemographic characteristics, comorbidities, and family history of mental illness were also collected. Multiple linear regression models were performed to explore factors associated with depression and anxiety.

Results

A total of 174 adult participants (≥18 years old) who had recently recovered from COVID-19 were interviewed. The mean PHQ-9 and GAD-7 scores were 7.53 (±5.04) and 3.77 (±4.47), respectively. About 68% of the participants had at least mild depression (PHQ-9 score of 5–9), whereas only 29.89% had at least mild anxiety (GAD-7 score of 5–9) during their infections with COVID-19. Multiple linear regression showed that females were more vulnerable to depression and anxiety disorders than their male counterparts were (β=3.071 and β=1.86, respectively). Notably, participants’ stigma scores were significantly associated with higher scores on depression and anxiety.

Conclusion

These findings highlight the negative consequences of COVID-19 infection on the mental health of recovered patients. Therefore, considerable attention from local and international health authorities is needed to improve the mental well-being of recovered COVID-19 patients.

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

BACKGROUND

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

SUBJECTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Protecting Mental Health Data Privacy in India: The Case of Data Linkage With Aadhaar

In an underprepared and under-resourced digital mental health system, the linkage of health and personal data with Aadhaar, a biometric system that provides a unique identification number to all Indian residents, poses significant privacy risks to individuals seeking mental health care. We discuss the challenges in protecting mental health data privacy due to these emerging digital health technologies.

Validation and Cultural Adaptation of Explanatory Model Interview Catalogue (EMIC) in Assessing Stigma among Recovered Patients with COVID-19 in Saudi Arabia

Stigma is a negative feeling affecting many patients with various health conditions, especially the contagious ones such as COVID-19. The Explanatory Model Interview Catalogue (EMIC) is one of the valid and reliable stigma-measuring tools; however, it has not been translated and validated in Arabic. Therefore, the aim of this study was to translate and validate the EMIC in Arabic among a sample of Arabic-speaking adults who recently recovered from COVID-19 in Saudi Arabia. The 12 items of the EMIC scale were forward- and backward-translated and reviewed by all authors to check the face and content validity prior to approving the final version of the Arabic 12-item EMIC. A total of 174 participants aged ≥18 years who contracted COVID-19 and recovered as of 29 July 2020 were interviewed. The Cronbach’s alpha of the Arabic version of the 12-item EMIC was 0.79, indicating an acceptable level of internal consistency. Using principal component analysis with varimax rotation, two factors explained more than 60% of the variance of the translated EMIC scale. The mean EMIC score was 5.91, implying a low level of stigma among participants. Married participants (β = 2.93; 95%CI 0.88 to 4.98, p = 0.005) and those with a family history of mental illness (β = 2.38; 95%CI 0.29 to 4.46, p = 0.025) were more likely to have higher EMIC scores in comparison to their counterparts who were unmarried and had no family history of mental illness. On the contrary, older adults were less likely to have high EMIC scores (β = −0.11; 95%CI −0.21 to −0.01, p = 0.03). Future studies with larger samples of patients with COVID-19 and various health conditions should be conducted to examine the validity and reliability of the Arabic version of the EMIC among different patient populations and to unveil the factors that may play a role in patients’ feelings of stigmatization in this part of the world.

Help-seeking for mental health concerns: review of Indian research and emergent insights

Purpose

The purpose of this review was to examine Indian research on help-seeking for mental health problems in adults.

Design/methodology/approach

Original Indian research studies on help-seeking for mental health, published from the year 2001−2019 were searched on PubMed, EBSCO, ProQuest and OVID using a set of relevant keywords. After applying exclusion criteria, 52 relevant research studies were identified.

Findings

The reviewed studies spanned a variety of themes such as barriers and facilitators to help-seeking, sources of help-seeking, causal attributions as well as other correlates of help-seeking, process of help-seeking and interventions to increase help-seeking. The majority of these studies were carried out in general community samples or treatment-seeking samples. Very few studies incorporated non-treatment seeking distressed samples. There is a severe dearth of studies on interventions to improve help-seeking. Studies indicate multiple barriers to seeking professional help and highlight that mere knowledge about illness and availability of professional services may be insufficient to minimize delays in professional help-seeking.

Originality/value

Help-seeking in the Indian context is often a family-based decision-making process. Multi-pronged help-seeking interventions that include components aimed at reducing barriers experienced by non-treatment seeking distressed persons and empowering informal support providers with knowledge and skills for encouraging professional help-seeking in their significant others may be useful.

Parenting skills of patients with chronic schizophrenia

AIM OF THE STUDY

This study aims to evaluate the parenting skills of patients with schizophrenia as perceived by themselves and their children and compare the same with a matched healthy control group of parents and their children.

MATERIALS AND METHODS

Fifty-one patients with schizophrenia and their 51 children were assessed on the Alabama Parenting Scale. A healthy control group of 51 parents and their children were also assessed for parenting.

RESULTS

The mean age of parents with schizophrenia was 45.23 years. Compared to the parents in the healthy control group, patients with schizophrenia reported deficits in the domains of positive involvement, positive parenting; more often report poor monitoring/supervision, and inconsistent discipline. When the children of patients with schizophrenia and children of healthy parents were compared, children of healthy control parents reported higher positive involvement, positive parenting; and lower corporal punishment and inconsistent discipline. Except for few associations, parenting was not affected by demographic and clinical profile of the patients with schizophrenia.

CONCLUSION

The present study suggests that patients with schizophrenia have deficits in parenting and there is a need to improve the parenting skills of the patients with schizophrenia.

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

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

Stigma in mental illness: Perspective from eight Asian nations

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Labels used for persons with severe mental illness and their stigma experience in North India

AIM

This study aimed to evaluate the extent to stigma experienced by the PMI in the hands of their family members and friends/colleagues in the form of commonly used labels and factors associated with use of various labels for persons with mental illnesses.

METHODOLOGY

191 patients with severe mental illness (120 patients with mood disorders and 71 patients with psychotic illness) were assessed using a self-designed questionnaire for the derogatory labels faced by patients in the hands of their family members and friends/colleagues.

RESULTS

60 % and 39.8 % of the patients reported of being teased by the family members and friends/colleagues respectively for being suffering from mental illness. The most commonly used label/adjective by the family members was Aalsi (lazy) (20.9 %), followed by sustt (lethargic) (15.2 %) and paagal (mad) (14.1 %). The commonly used labels/adjectives by friends/colleagues were paagal (mad) (6.3 %), followed by darpok (coward) (5.2 %). Mean number of labels used by the family members and friends/co-workers were 5.93 and 3.4 respectively. Around one third of the patients (32.5 %) reported that seeking treatment is associated with facing these labels and due to the same they stopped or wanted to stop their treatment. Significantly higher numbers of labels were used for patients with psychotic disorders, when compared to those with affective disorders. Poor functioning was associated with use of significantly higher number of derogatory labels.

CONCLUSIONS

Stigmatizing labels are commonly used by family members and friends of the patients with severe mental illness and these cause significant distress to the patients. There is a need to make the society aware that there is a need to stop use of these derogatory labels.

Impact of a community-based mental health awareness program on changing attitudes of the general population toward mental health in Gujarat, India - A study of 711 respondents

CONTEXT

In India, there is a large mental illness treatment gap, especially in rural areas. Contributors to this problem include stigma and a general lack of mental health knowledge. The State Health Department of Gujarat, India, released a video tool, in 2003, with the goal being to educate the community on topics related to mental health.

AIMS

The aim of this study was to evaluate the ability of the government-developed video tool to improve attitudes toward mental health in rural Gujarat.

SETTINGS AND DESIGN

Eight hundred and sixty-five individuals, in 17 villages in Gujarat, agreed to attend a mental health awareness workshop that used the government-developed video tool. One workshop was held in each village. A structured questionnaire evaluating attitudes was administered to the participants before and after the workshop.

SUBJECTS AND METHODS

government-developed video tool, standardized questionnaire for attitude evaluation.

STATISTICAL ANALYSIS USED

A McNemar's test was used to evaluate the difference between pre- and post-scores.

RESULTS

A total of 711 participants completed the pre- and post-questionnaire. Attitudes related to psychosis, suicidal ideation, postpartum depression, learning disability, general mental illness, and perceptions of dangerousness showed significantly favorable improvement (P <.005). Attitudes related to substance abuse worsened (P < 0.005).

CONCLUSIONS

Results suggest that a government-developed video tool can successfully improve short-term attitudes. Attitudes toward substance abuse may require a different approach than attitudes toward other types of mental illness.

"He can send her to her parents": The interaction between marriageability, gender and serious mental illness in rural Ethiopia

BACKGROUND

For women in most low- and middle-income countries, the diagnosis with serious mental illness (SMI) leads to stigma and challenges related to starting or maintaining marriages. The purpose of this qualitative study was to explore perspectives on marriage, divorce and family roles of women with SMI in rural Ethiopia.

METHODS

A qualitative study was conducted in a rural setting of Butajira, South Central Ethiopia. A total of 39 in-depth interviews were carried out with service users (n = 11), caregivers (n = 12), religious leaders (n = 6), health extension workers (n = 4), police officers (n = 2), teachers (n = 2) and government officials (n = 2). Data were analyzed using a thematic approach.

RESULTS

Three themes emerged. (1) Marriage and SMI: Chances of getting married for individuals with SMI in general was perceived to be lower: Individuals with SMI experienced various challenges including difficulty finding romantic partner, starting family and getting into a long-term relationship due to perceived dangerousness and the widespread stigma of mental illness. (2) Gendered experiences of marriageability: Compared to men, women with SMI experienced disproportionate levels of stigma which often continued after recovery. SMI affects marriageability for men with SMI, but mens' chances of finding a marital partner increases following treatment. For women in particular, impaired functioning negatively affects marriageability as ability to cook, care and clean was taken as the measure of suitability. (3) Acceptability of divorce and separation from a partner with SMI: Divorce or separation from a partner with SMI was considered mostly acceptable for men while women were mostly expected to stay married and care for a partner with SMI. For men, the transition from provider to dependent was often acceptable. However, women who fail to execute their domestic roles successfully were considered inept and would be sent back to their family of origin.

CONCLUSION

Women with SMI or those married to partners with SMI are at greater disadvantage. Reducing vulnerabilities through stigma reduction efforts such as community outreach and mental health awareness raising programs might contribute for better social outcomes for women with SMI.

Facets of clinical stigma after attempted suicide in Mumbai, India

Community stigma studies may neglect clinically relevant experience and views of stigma that are important features of mental health problems. After attempting suicide, patients in a hospital emergency ward in Mumbai, India, were assessed for stigma referring to underlying prior problems motivating their deliberate self-harm (DSH) event, the DSH event itself and serious mental illness generally based on both anticipated community views and distinctive personal views. In this cultural epidemiological study of 196 patients, assessment items and four corresponding indexes were analysed and compared on a four-point scale, 0 to 3, for prominence of indicated stigma. Narratives from patients with high, low and discordant levels of stigma for prior problems and DSH events were analysed and compared. Disclosure, critical opinions of others and problems to marry were greater concerns for DSH events than prior problems. Problem drinking, unemployment, and sexual or financial victimization were common features of prior problems. Impulsivity of the DSH event and externalizing blame were features of lower levels of stigma. Ideas about most people's views of serious mental illness were regarded as more stigmatizing than patients' prior problems and DSH event; patients' personal views of serious mental illness were least stigmatizing. Findings suggest linking suicidality and stigmatized mental illness may discourage help seeking. Suicide prevention strategies should therefore emphasize available help needed for severe stress instead of equating suicidality and mental illness. Findings also indicate the relevance of assessing clinical stigma in a cultural formulation and the value of integrated qualitative and quantitative stigma research methods.

Sex work-related stigma: Experiential, symbolic and structural forms in the health systems of Delhi, India

Sex work-related stigma is prevalent in urban India. While HIV-stigma is often discussed in urban Indian health contexts, rarely is sex work-related stigma investigated as it shapes sex workers' health experiences. This paper discusses the findings of an ethnographic study with women who practice sex work (WPSW), healthcare providers, and NGO workers in Delhi, India over seven months in 2017. We apply a tri-tiered model of stigma as constituted of experiential, symbolic, and structural forms, to better understand how WPSW experience sex work-related stigma as it relates to their health. Identifying and understanding manifestations and experiences of stigma is crucial to supporting WPSW health. We conclude that in the face of criminalized legal contexts, both non-governmental and governmental interventions to improve WPSW's health must contend with their own tendencies to reinforce prevailing stereotypes and symbols that stigmatize sex work and the people who engage in it.

Out of the silos: identifying cross-cutting features of health-related stigma to advance measurement and intervention

BACKGROUND

Many health conditions perceived to be contagious, dangerous or incurable, or resulting in clearly visible signs, share a common attribute - an association with stigma and discrimination. While the etiology of stigma may differ between conditions and, sometimes, cultural settings, the manifestations and psychosocial consequences of stigma and discrimination are remarkably similar. However, the vast majority of studies measuring stigma or addressing stigma through interventions employ a disease-specific approach.

MAIN BODY

The current paper opposes this siloed approach and advocates a generic concept of 'health-related stigma' in both stigma measurement and stigma interventions. Employing a conceptual model adapted from Weiss, the current paper demonstrates the commonalities among several major stigmatized conditions by examining how several stigma measurement instruments, such as the Social Distance Scale, Explanatory Model Interview Catalogue, Internalized Stigma of Mental Illness, and Berger stigma scale, and stigma reduction interventions, such as information-based approaches, contact with affected persons, (peer) counselling, and skills building and empowerment, were used successfully across a variety of conditions to measure or address stigma. The results demonstrate that 'health-related stigma' is a viable concept with clearly identifiable characteristics that are similar across a variety of stigmatized health conditions in very diverse cultures.

CONCLUSION

A more generic approach to the study of health-related stigma opens up important practical opportunities - cross-cutting measurement and intervention tools are resource saving and easier to use for personnel working with multiple conditions, allow for comparison between conditions, and recognize the intersectionality of many types of stigma. Further research is needed to build additional evidence demonstrating the advantages and effectiveness of cross-condition approaches to stigma measurement and interventions.

Mental Health Literacy: A Review of What It Is and Why It Matters

An increasing number of scholarly works have attempted to understand the reasons for poor rates of help-seeking for symptoms of mental health disorders all around the world. One particular body of work has focused on “mental health literacy” (MHL), defined as knowledge about mental health disorders that is associated with their recognition, management, and prevention. In this article, we report a nonsystematic review of studies on MHL, to give nonexpert academics, policymakers, and practitioners an understanding of the field. We find that studies consistently show that the general public have relatively poor recognition of the symptoms of mental health disorders and appear to emphasize self-help over traditional medical treatments. In addition, we find that there are age, gender, educational, urban−rural, and cross-cultural differences in MHL, which may differentially affect rates of help-seeking in different contexts. Implications and future directions for research are considered in conclusion.

Social Distance and Community Attitudes Towards People with Psycho-Social Disabilities in Uttarakhand, India

Stigma is an important contributor to the large treatment gap for people with mental and psycho-social disabilities (PPSD) in India. Social distance as assessed by willingness to engage in relationships with PPSD is a proxy measure of stigma and potential discrimination. In North India, investigations of community attitudes towards PPSD have been limited. To describe attitudes towards people with depression and psychosis, a community sample of 960 adults in Dehradun district, India from 30 randomised clusters, was surveyed using a validated tool to assess social distance, beliefs and attitudes related to mental illness. Participants preferred greater social distance from a person with psychosis than a person with depression. Beliefs and attitudes around mental illness were diverse reflecting a wide spread of belief frameworks. After controlling for confounding, there was increased social distance among people who believed PPSD were dangerous. Factors that reduced social distance included familiarity with PPSD, and belief that PPSD can recover. Attitudes to PPSD, stigma and social distance are complex and likely to require complex responses that include promoting awareness of mental health and illness, direct contact with PPSD and increasing access to care for PPSD.

Predictors of Family Stress in Taking Care of Patients with Schizophrenia

Introduction: Taking care of schizophrenia patients is challenging and causes stress for the family involved. The study was conducted to identify the predictors of family stress present when taking care of a patient with schizophrenia. The ABCX Stress Theory of Hill was used as the theoretical framework.Methods: This study used a correlational design. The sample was 137 families who were caring for patients with schizophrenia at the Menur Mental Hospital, Surabaya, Indonesia. The sample was obtained by way of purposive sampling. The data was collected by a questionnaire and analysed by multiple regression to determine the relationship of the family’s structure, family knowledge, the burden of care, stigma, social support, the patient's illness duration, the patient’s frequency of relapse and the patient's severity level with family stress.Results: The results showed that the family’s stress was predicted by the family’s structure (p=0.029), stigma (p=0.000), the burden of care (p=0.000), and the patient’s frequency of relapse (p=0.005). The burden of care was the strongest predictor of family stress (Beta= 0.619).Conclusion: The patient's frequency of relapse and stigma were other kinds of family stressor. The stressors stimulated a negative perception, called the care burden. Limited adequacy of the family structure-function will inhibit the family in using other resources, creating family stress. Nurses may develop an assessment format that consists of the family stress predictors in order to create a nursing care plan specific to reframing the techniques of family stress management.

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.

Multiple barriers to participation for people with psychosocial disability in Dehradun district, North India: a cross-sectional study

OBJECTIVES

This study used a population-based cross-sectional survey to describe the prevalence of psychosocial disability and unmet need for access to services in North India.

SETTING

This study was conducted in Dehradun district, Uttarakhand, in 2014.

PARTICIPANTS

A population-based sample of 2441 people over the age of 18 years.

PRIMARY OUTCOME MEASURES

The Rapid Assessment of Disability survey tool identified people with disability and used an adapted version of the Kessler scale to identify those with psychosocial disability. It additionally collected information on socioeconomic variables, access to community services and barriers to participation. Prevalence of psychosocial disability and unmet needs and descriptions of barriers to services were calculated, and multivariable logistic regression was used to assess associations between risk factors and psychosocial disability.

RESULTS

Prevalence of psychosocial disability was 4.8% and 75% of participants with psychological distress also reported comorbid functional impairments. Adjusted ORs for depression of more than two were found for people who were unschooled, unemployed and of moderate or poor socioeconomic status. The unmet need for access to services was significantly higher in every domain for people with psychosocial disability and was more than 25% in the areas of employment, health service access and community consultation. People with psychosocial disability encountered greater barriers in each domain compared with controls.

CONCLUSIONS

People who are poor, uneducated and unemployed are two to four times more likely to have psychosocial disability in Dehradun district. They face unmet needs in accessing community services and perceive negative social attitudes, lack of physical accessibility and lack of information as barriers limiting their participation. Social policy must increase access to education and reduce poverty but additionally ensure action is taken in all community services to increase information, physical accessibility and social inclusion of people with psychosocial and other forms of disability.

Stigma experienced by patients with severe mental disorders: A nationwide multicentric study from India

This study aimed to evaluate the stigma and its correlates among patients with severe mental disorders. Patients with diagnosis of schizophrenia (N = 707), bipolar disorder (N = 344) and recurrent depressive disorder (N = 352) currently in clinical remission from 14 participating centres were assessed on Internalized Stigma of Mental Illness Scale (ISMIS). Patients with diagnosis of schizophrenia experienced higher level of alienation, sterotype endorsement, discrimination experience and total stigma when compared to patients with bipolar disorder and recurrent depressive disorder. Patients with bipolar disorder experienced higher stigma than those with recurrent depressive disorder in the domain of stigma resistance only. Overall compared to affective disorder groups, higher proportion of patients with schizophrenia reported stigma in all the domains of ISMIS. In general in all the 3 diagnostic groups' stigma was associated with shorter duration of illness, shorter duration of treatment and younger age of onset. To conclude, this study suggests that compared to affective disorder, patients with schizophrenia experience higher self stigma. Higher level of stigma is experienced during the early phase of illness. Stigma intervention programs must focus on patients during the initial phase of illness in order to reduce the negative consequences of stigma.

Stigma towards people with mental disorders and its components - a perspective from multi-ethnic Singapore

AIMS

The current study aimed to: (i) describe the extent of overall stigma as well as the differences in stigma towards people with alcohol abuse, dementia, depression, schizophrenia and obsessive compulsive disorder, as well as (ii) establish the dimensions of stigma and examine its correlates, in the general population of Singapore, using a vignette approach.

METHODS

Data for the current study came from a larger nation-wide cross-sectional study of mental health literacy conducted in Singapore. The study population comprised Singapore Residents (Singapore Citizens and Permanent Residents) aged 18-65 years who were living in Singapore at the time of the survey. All respondents were administered the Personal and Perceived scales of the Depression Stigma scale and the Social Distance scale to measure personal stigma and social distance, respectively. Weighted mean and standard error of the mean were calculated for continuous variables, and frequencies and percentages for categorical variables. Exploratory structural equation modelling and confirmatory factor analysis were used to establish the dimensions of stigma. Multivariable linear regressions were conducted to examine factors associated with each of the stigma scale scores.

RESULTS

The mean age of the respondents was 40.9 years and gender was equally represented (50.9% were males). The findings from the factor analysis revealed that personal stigma formed two distinct dimensions comprising 'weak-not-sick' and 'dangerous/unpredictable' while social distance stigma items loaded strongly into a single factor. Those of Malay and Indian ethnicity, lower education, lower income status and those who were administered the depression and alcohol abuse vignette were significantly associated with higher weak-not-sick scores. Those of Indian ethnicity, 6 years of education and below, lower income status and those who were administered the alcohol abuse vignette were significantly associated with higher dangerous/unpredictable scores. Those administered the alcohol abuse vignette were associated with higher social distance scores.

CONCLUSION

This population-wide study found significant stigma towards people with mental illness and identified specific groups who have more stigmatising attitudes. The study also found that having a friend or family member with similar problems was associated with having lower personal as well as social distance stigma. There is a need for well-planned and culturally relevant anti-stigma campaigns in this population that take into consideration the findings of this study.

Stigma experienced by caregivers of patients with severe mental disorders: A nationwide multicentric study

BACKGROUND

Stigma is very common among caregivers of patients with severe mental disorder; however, there is lack of national level data from India.

AIM

To assess affiliate stigma and its correlates among caregivers of patients with severe mental disorders.

METHOD

For this, caregivers of patients with schizophrenia ( N = 707), bipolar disorder ( N = 344) and recurrent depressive disorder ( N = 352) were assessed on Stigma scale for Caregivers of People with Mental Illness and General Health Questionnaire.

RESULTS

Caregivers of patients with schizophrenia reported significantly higher stigma than patients with bipolar disorder and recurrent depressive disorder. Caregiver of patients with bipolar disorder reported significantly greater stigma than the caregivers of patients with recurrent depressive disorder. Higher caregiver stigma in all the diagnostic groups was associated with higher psychological morbidity in caregivers. Higher stigma in caregivers of schizophrenia was seen when the patient had younger age of onset and longer duration of treatment. In the bipolar disorder group, higher stigma in caregivers was seen when patient had higher residual manic symptoms.

CONCLUSION

This study suggests that caregivers of patients with schizophrenia experience higher stigma than the caregivers of patients with bipolar disorder and recurrent depressive disorder. Higher stigma is associated with higher psychological morbidity in the caregivers. Therefore, the clinicians managing patients with severe mental disorders must focus on stigma and psychological distress among the caregivers and plan intervention strategies to reduce stigma.

Experiences of stigma and discrimination faced by family caregivers of people with schizophrenia in India

Stigma associated with schizophrenia significantly affects family caregivers, yet few studies have examined the nature and determinants of family stigma and its relationship to their knowledge about the condition. This paper describes the experiences and determinants of stigma reported by the primary caregivers of people living with schizophrenia (PLS) in India. The study used mixed methods and was nested in a randomised controlled trial of community care for people with schizophrenia. Between November 2009 and October 2010, data on caregiver stigma and functional outcomes were collected from a sample of 282 PLS–caregiver dyads. In addition, 36 in-depth-interviews were conducted with caregivers. Quantitative findings indicate that ‘high caregiver stigma’ was reported by a significant minority of caregivers (21%) and that many felt uncomfortable to disclose their family member's condition (45%). Caregiver stigma was independently associated with higher levels of positive symptoms of schizophrenia, higher levels of disability, younger PLS age, household education at secondary school level and research site. Knowledge about schizophrenia was not associated with caregiver stigma. Qualitative data illustrate the various ways in which stigma affected the lives of family caregivers and reveal relevant links between caregiver-stigma related themes (‘others finding out’, ‘negative reactions’ and ‘negative feelings and views about the self’) and other themes in the data.

Findings highlight the need for interventions that address both the needs of PLS and their family caregivers. Qualitative data also illustrate the complexities surrounding the relationship between knowledge and stigma and suggest that providing ‘knowledge about schizophrenia’ may influence the process of stigmatisation in both positive and negative ways. We posit that educational interventions need to consider context-specific factors when choosing anti-stigma-messages to be conveyed. Our findings suggest that messages such as ‘recovery is possible’ and ‘no-one is to blame’ may be more helpful than focusing on bio-medical knowledge alone.

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Experiences of being blamed and worries about marital prospects were salient.

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Caregivers' and PLS' experiences of stigma were determined by similar factors.

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Knowledge was linked to stigma in qualitative but not in quantitative analyses.

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Context-specific messages rather than biomedical knowledge may help reduce stigma.

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Family caregivers need access to emotional and social support in their own right.

Stigma and its correlates among patients with bipolar disorder: A study from a tertiary care hospital of North India

This study aimed to assess stigma and its sociodemographic and clinical correlates among patients with bipolar disorder while in remission. 185 patients currently in remission were assessed on Internalized Stigma of Mental Illness Scale (ISMIS) for internalized stigma, Explanatory Model Interview Catalogue Stigma Scale for perceived stigma and Participation scale for restriction of activities. About 28% patients reported moderate to high level of self stigma as assessed by ISMIS total score. Discrimination experience (38.9%) was reported to be the most commonly experienced self stigma followed by alienation (28.6%) and social withdrawal (28.6%). On the participation scale, about two-fifth (42%) of the participants had severe restriction of activities. Internalized stigma was higher among those with lower age and lesser income. Higher level of stigma was associated with shorter mean duration of remission, income, mean duration of depressive episodes, higher severity of residual depressive symptoms and current level of functioning. Higher internalized stigma was associated with greater restriction in participation of activities. To conclude, present study suggests that self stigma is highly prevalent among patients with bipolar disorder in India and is associated with clinical variables like duration of depressive episodes and level of functioning.

Stigma and its correlates among caregivers of schizophrenia: A study from North India

This study aimed to study stigma experienced by caregivers of patients with schizophrenia. One hundred caregivers of patients with schizophrenia were evaluated on Stigma scale for caregivers of people with mental illness (CPMI), Explanatory model interview catalogue stigma scale (EMIC), General health questionnaire-12 (GHQ), Self-report attitude towards medications questionnaire and Knowledge of mental illness scale (KMI). On CPMI the score was higher for affective component (2.3±0.5) than for cognitive (1.9±0.9) and behavioural (1.8±0.6) components. More than half of caregivers 'agreeing' or 'strongly agreeing' on 20 out of 22 items of CPMI indicated high level of stigma. On EMIC the stigma score was 21.7±6.3. Higher level of affiliate and/or associative stigma was associated with shorter duration of illness and treatment, shorter duration of being in the caregiver role, younger, female and non-earning caregivers, prescription of higher number of pills, caregivers who less often accompany the patient to the hospital and caregivers experienced more psychological morbidity. To conclude this study suggests that caregivers of patients with schizophrenia experience substantial stigma; hospital and community level programs and services are required to reduce and prevent the same.

Stigma and its correlates in patients with schizophrenia attending a general hospital psychiatric unit

BACKGROUND

Very few studies from India have studied stigma experienced by patients with schizophrenia.

AIM OF THE STUDY

To study stigma in patients with schizophrenia (in the form of internalized stigma, perceived stigma and social-participation-restriction stigma) and its relationship with specified demographic and clinical variables (demographic variables, clinical profile, level of psychopathology, knowledge about illness, and insight).

MATERIALS AND METHODS

Selected by purposive random sampling, 100 patients with schizophrenia in remission were evaluated on internalized stigma of mental illness scale (ISMIS), explanatory model interview catalog stigma scale, participation scale (P-scale), positive and negative syndrome scale for schizophrenia, global assessment of functioning scale, scale to assess unawareness of mental disorder, and knowledge of mental illness scale.

RESULTS

On ISMIS scale, 81% patients experienced alienation and 45% exhibited stigma resistance. Stereotype endorsement was seen in 26% patients, discrimination experience was faced by 21% patients, and only 16% patients had social withdrawal. Overall, 29% participants had internalized stigma when total ISMIS score was taken into consideration. On P-scale, 67% patients experienced significant restriction, with a majority reporting moderate to mild restriction. In terms of associations between stigma and sociodemographic variables, no consistent correlations emerged, except for those who were not on paid job, had higher participation restriction. Of the clinical variables, level of functioning was the only consistent predictor of stigma. While better knowledge about the disorder was associated with lower level of stigma, there was no association between stigma and insight.

CONCLUSION

Significant proportion of patients with schizophrenia experience stigma and stigma is associated with lower level of functioning and better knowledge about illness is associated with lower level of stigma.

Reducing the stigma of mental illness

This paper presents a narrative review of anti-stigma programming using examples from different countries to understand and describe current best practices in the field. Results highlight the importance of targeting the behavioural outcomes of the stigmatization process (discrimination and social inequity), which is consistent with rights-based or social justice models that emphasize social and economic equity for people with disabilities (such as equitable access to services, education, work, etc.). They also call into question large public education approaches in favour of more targeted contact-based interventions. Finally, to add to the research base on best practices, anti-stigma programs are encouraged to create alliances with university researchers in order to critically evaluate their activities and build better, evidence informed practices.

Evidence for effective interventions to reduce mental health-related stigma and discrimination in the medium and long term: systematic review

BACKGROUND

Most research on interventions to counter stigma and discrimination has focused on short-term outcomes and has been conducted in high-income settings.

AIMS

To synthesise what is known globally about effective interventions to reduce mental illness-based stigma and discrimination, in relation first to effectiveness in the medium and long term (minimum 4 weeks), and second to interventions in low- and middle-income countries (LMICs).

METHOD

We searched six databases from 1980 to 2013 and conducted a multi-language Google search for quantitative studies addressing the research questions. Effect sizes were calculated from eligible studies where possible, and narrative syntheses conducted. Subgroup analysis compared interventions with and without social contact.

RESULTS

Eighty studies (n = 422 653) were included in the review. For studies with medium or long-term follow-up (72, of which 21 had calculable effect sizes) median standardised mean differences were 0.54 for knowledge and -0.26 for stigmatising attitudes. Those containing social contact (direct or indirect) were not more effective than those without. The 11 LMIC studies were all from middle-income countries. Effect sizes were rarely calculable for behavioural outcomes or in LMIC studies.

CONCLUSIONS

There is modest evidence for the effectiveness of anti-stigma interventions beyond 4 weeks follow-up in terms of increasing knowledge and reducing stigmatising attitudes. Evidence does not support the view that social contact is the more effective type of intervention for improving attitudes in the medium to long term. Methodologically strong research is needed on which to base decisions on investment in stigma-reducing interventions.

The Ache of Exile

Stigma associated with mental illness is one of the major impediments in evolving effective treatment interventions to address the burden associated with these disorders. Research enquiries in the Indian context have explored various facets of the phenomenon. While providing an overview of these studies, the present paper draws attention to the fact that stigma of mental illness is not solely a reflection of the social determinants of the problem. It is equally indicative of structural inequalities of power which result in rejection, marginalisation and social exclusion of the individuals afflicted with mental illness.

Autism spectrum disorder etiology: Lay beliefs and the role of cultural values and social axioms

Recent research examining the explanations given by the public (i.e. lay beliefs) for autism spectrum disorder often reveals a reasonably accurate understanding of the biogenetic basis of the disorder. However, lay beliefs often manifest aspects of culture, and much of this work has been conducted in western cultures. In this study, 215 undergraduate university students in Macau, a Special Administrative Region of China, completed self-report measures assessing two beliefs concerning autism spectrum disorder etiology: (1) a belief in parental factors and (2) a belief in genetic factors. Potential correlates of lay beliefs were sought in culture-specific values, and more universal social axioms. Participants were significantly more likely to endorse parenting, relative to genetic factors, as etiological. A perceived parental etiology was predicted by values of mind-body holism. Beliefs in a parental etiology were not predicted by values assessing collectivism, conformity to norms, a belief in a family's ability to obtain recognition through a child's achievement, or interpersonal harmony, nor by the social axioms measured (e.g. social cynicism, reward for application, social complexity, fate control, and religiosity). Beliefs in a genetic etiology were not predicted by either culture-specific values or social axioms. Implications of the current results are discussed.

Under the banyan tree--exclusion and inclusion of people with mental disorders in rural North India

Background

Social exclusion is both cause and consequence of mental disorders. People with mental disorders (PWMD) are among the most socially excluded in all societies yet little is known about their experiences in North India. This qualitative study aims to describe experiences of exclusion and inclusion of PWMD in two rural communities in Uttar Pradesh, India.

Methods

In-depth interviews with 20 PWMD and eight caregivers were carried out in May 2013. Interviews probed experiences of help-seeking, stigma, discrimination, exclusion, participation, agency and inclusion in their households and communities. Qualitative content analysis was used to generate codes, categories and finally 12 key themes.

Results

A continuum of exclusion was the dominant experience for participants, ranging from nuanced distancing, negative judgements and social isolation, and self-stigma to overt acts of exclusion such as ridicule, disinheritance and physical violence. Mixed in with this however, some participants described a sense of belonging, opportunity for participation and support from both family and community members.

Conclusions

These findings underline the urgent need for initiatives that increase mental health literacy, access to services and social inclusion of PWMD in North India, and highlight the possibilities of using human rights frameworks in situations of physical and economic violence. The findings also highlight the urgent need to reduce stigma and take actions in policy and at all levels in society to increase inclusion of people with mental distress and disorders.

Human rights violations among economically disadvantaged women with mental illness: An Indian perspective

BACKGROUND

Globally women confront manifold violations of human rights and women with poverty and mental illness are doubly disadvantaged.

AIM

The aim was to examine the influence of poverty in meeting human rights needs among recovered women with mental illness at family and community level.

MATERIALS AND METHODS

This was a descriptive study carried out among randomly selected (n = 100) recovered women with mental illness at a tertiary care center. Data were collected through face-to-face interview using structured needs assessment questionnaire.

RESULTS

Our findings revealed that below poverty line (BPL) participants were not satisfied in meeting their physical needs such as "access to safe drinking water" (χ(2) = 8.994, P < 0.02), "served in the same utensils" (χ(2) = 13.648, P < 0.00), had adequate food (χ(2) = 11.025, P < 0.02), and allowed to use toilet facilities (χ(2) = 13.565, P < 0.00). The human rights needs in emotional dimension, that is, afraid of family members (χ(2) = 8.233, P < 0.04) and hurt by bad words (χ(2) = 9.014, P < 0.02) were rated higher in above poverty line (APL) participants. Similarly, 88.9% of women from APL group expressed that they were discriminated and exploited by the community members (χ(2) = 17.490, P < 0.00). More than three-fourths of BPL participants (76.1%) believed that there were wondering homeless mentally ill in their community (χ(2) = 11.848, P < 0.01).

CONCLUSION

There is an urgent need to implement social welfare programs to provide employment opportunities, disability allowance, housing and other social security for women with mental illness. Further, mental health professionals play an essential role in educating the family and public regarding human rights of people with mental illness.

Stigma of mental illness: An interventional study to reduce its impact in the community

BACKGROUND

Research literature has documented the nature of stigma associated with mental illness (MI) and its consequences in all spheres of life of ill persons and their families. It is also suggested that there is a need to develop intervention strategies to reduce stigma. However, very little is reported about these initiatives in the Indian context.

AIM

To understand the nature of stigma associated with MI in a rural and semi-urban community in India and to develop an intervention package and study its impact.

MATERIALS AND METHODS

The study adopted a pre- and post-experimental/action research design with a random sample of community members including persons with chronic MI and their caregivers from rural and semi-urban areas. A semi structured interview schedule was used to assess the nature of stigma. An intervention package, developed on the basis of initial findings, was administered, and two post assessments were carried out.

RESULTS

Stigmatized attitude related to various aspects of MI were endorsed by the respondents. Caregivers had less stigmatizing attitude than the members of the community. Postintervention assessments (PIAs) revealed significant changes in attitudes towards some aspects of MI and this improved attitude was sustained during the second PIA, that is, after 3 months of intervention.

CONCLUSION

People in the rural and semi-urban community have stigmatizing attitude toward MI. Intervention package focusing on the relevant aspect of MI can be used for reducing stigma of MI.

"Maybe at birth there was an injury": drivers and implications of caretaker explanatory models of autistic characteristics in Kerala, India

Explanatory models (EMs) are the way people explain the presence and meaning of an illness or disability and are reliant on and reflective of culturally specific values of normalcy, disability, health, and illness. EMs about autism spectrum disorder (ASD) are particularly revealing because there is no known cause, and so people can explain this disability in ways more appropriate for and useful to them. This article presents caretaker EMs about children with autistic characteristics in Kerala, India. I argue that the reliance on biological, but not genetic, causal models is reflective of the state's high access to biomedical heath care. These EMs are used to deflect the stigma of 'bad blood' and reflect a nuanced relationship between stigma and biological EMs. Understanding how caretakers talk about ASD and related conditions is critical for anyone interested in engaging in crosscultural or international autism-related work.

Experiences of stigma and discrimination of people with schizophrenia in India

Stigma contributes greatly to the burden of schizophrenia and is a major obstacle to recovery, yet, little is known about the subjective experiences of those directly affected in low and middle income countries. This paper aims to describe the experiences of stigma and discrimination of people living with schizophrenia (PLS) in three sites in India and to identify factors influencing negative discrimination.

The study used mixed methods and was nested in a randomised controlled trial of community care for schizophrenia. Between November 2009 and October 2010, data on four aspects of stigma experienced by PLS and several clinical variables were collected from 282 PLS and 282 caregivers and analysed using multivariate regression. In addition, in-depth-interviews with PLS and caregivers (36 each) were carried out and analysed using thematic analysis.

Quantitative findings indicate that experiences of negative discrimination were reported less commonly (42%) than more internalised forms of stigma experience such as a sense of alienation (79%) and significantly less often than in studies carried out elsewhere. Experiences of negative discrimination were independently predicted by higher levels of positive symptoms of schizophrenia, lower levels of negative symptoms of schizophrenia, higher caregiver knowledge about symptomatology, lower PLS age and not having a source of drinking water in the home. Qualitative findings illustrate the major impact of stigma on ‘what matters most’ in the lives of PLS and highlight three key domains influencing the themes of 'negative reactions' and ‘negative views and feelings about the self’, i.e., ‘others finding out’, ‘behaviours and manifestations of the illness’ and ‘reduced ability to meet role expectations’.

Findings have implications for conceptualising and measuring stigma and add to the rationale for enhancing psycho-social interventions to support those facing discrimination. Findings also highlight the importance of addressing public stigma and achieving higher level social and political structural change.

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Internalised experiences of stigma were reported more commonly than discrimination.

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A range of negative reactions beyond ‘discrimination’ led to feelings of devaluation.

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Negative discrimination was predicted by illness features, e.g., positive symptoms.

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Negative reactions were also linked to reduced ability to meet role expectations.

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What mattered most to PLS was to achieve role expectations in marriage and work.

Stigma and discrimination as a barrier to mental health service utilization in India

Stigma towards, and discrimination against, people with mental disorders is an important barrier to mental health service utilization in India. It contributes to delays in seeking care, impedes timely diagnosis and treatment for mental disorders, serves as an impediment to recovery and rehabilitation, and ultimately reduces the opportunity for fuller participation in life. In India there is a need to generate evidence base for context specific interventions that will address negative attitudes towards people with mental disorders and ensure implementation of these interventions by involving users, care-givers, community health workers and mental health service providers.

Impact of socio-economic status in meeting the needs of people with mental illness; human rights perspective

The present descriptive study investigated the impact of socio-economic status in meeting the human rights needs among randomly selected recovered psychiatric patients (n = 100) at a tertiary care center. Data was collected through face to face interview, using structured Needs Assessment Questionnaire. The findings revealed that the participants from below poverty line were deprived of physical needs such as 'electricity facilities' (χ (2) = 6.821, p < .009) 'safe drinking water' (χ (2) = 13.506, p < .004) and purchasing medications (χ (2) = 9.958, p < .019). Conversely, participants from above poverty line were dissatisfied in emotional needs dimension i.e. 'commenting on physical appearance (χ (2) = 8.337, p < .040), afraid of family members (χ (2) = 17.809, p < .000). Thus, there is an urgent need to implement mental illness awareness campaigns and government should take active steps for providing employment, disability pension, free housing, free treatment and free transportation service for people with mental illness to attend hospital or rehabilitation centres.

Caregiving of children with intellectual disabilities in China--an examination of affiliate stigma and the cultural thesis

BACKGROUND

While caregivers of children with intellectual disabilities are burdened in every part of the world, it is suspected that particular contexts may make the situation worse. There is little literature on caregivers in China, where familial and clan responsibility rather than individual effort is emphasised, and where communal support, while treasured, is often lacking.

METHOD

A total of 211 caregivers in two cities, one with and the other without randomised design, participated in a survey study that assessed affiliated stigma, loss of face, anxiety, mental health and empowerment.

RESULTS

A proportion of 60.6% of participants were found to be conspicuous cases with mental disturbance of a level which required further professional attention. Participants with better resource appeared to have coped better, enjoying lower psychological distress, lower anxiety and a higher level of personal empowerment. Multiple regression analysis revealed that mental health is related to the affective dimension of affiliated stigma, loss of face and anxiety level. This was found to account for more than half the variance (55%).

DISCUSSION

The subjective burden of care occurs not in isolation but in a cultural field. Chinese caregiving is characterised by a lack of formal support, and such cultural concerns as loss of face and strong affiliated stigma. This socio-political context makes caregiving all the more challenging. The situation has to be addressed by both practitioners and policy makers if family caregiving is to be valued and made sustainable.