The relationship between mental illness severity and stigma

The care of patients with psychiatric symptoms in general hospitalisation units: A phenomenological study

INTRODUCTION

The objective of this study was to explore the approach to patients with psychiatric symptoms by nursing professionals in general hospitalisation units in the city of Medellín, Colombia.

METHODS

A qualitative study with the method of interpretive phenomenology. 11 nursing professionals from general hospitalisation units in the city of Medellín, Colombia participated. The information analysis was processed according to the Phenomenological Interpretive Analysis method and with the support of the NVIVO Plus 12 software.

RESULTS

The nurses' experience is described through three themes: representations of the patient with psychiatric symptoms, the patient as aggressive, violent and unpredictable; feeling fearful while providing care, caring for others in the midst of prevention, fear and stress, and being in a chaotic situation, a circumstance that gets out of control and alters the dynamics of the hospitalisation unit.

CONCLUSIONS

Caring for patients with psychiatric symptoms is stressful, especially when nursing professionals perceive a lack of support from other colleagues and from the hospital administration. The above favours the development of alterations in the professional's physical and mental health.

'Severe mental illness': Uses of this term in physical health support policy, primary care practice, and academic discourses in the United Kingdom

The term severe mental illness (SMI) is often used in academic work, primary care practice, and policy, acknowledging the health disparities experienced by, and need for improved support for, this population. However, here we draw from the varied experiences of our authorship team to reflect on some problematic operationalisations of the term SMI and its usage, specifically in policy, primary care practice, and academic discourses in England and the UK. Benefits of the SMI label in accessing specialised services are evident but, in this commentary, we start a discussion on its necessity and unintended consequences for wider health support. We focus on physical health support specifically. We hope that this commentary encourages dialogue among practitioners, researchers, stakeholders and commissioners concerning wider uses of the term SMI.

A Comparison of Social Exclusion Towards People with Depression or Chronic Back Pain

Objectives

Research comparing mental and physical health stigma is scarce. The aim of this study was to compare social exclusion towards hypothetical males and females with depression or chronic back pain. Furthermore, the study investigated whether social exclusion is associated with participant's empathy and personality traits, while controlling for their sex, age and personal exposure to mental/physical chronic health conditions.

Design

This study employed a cross-sectional questionnaire design.

Methods

Participants (N = 253) completed an online vignette-based questionnaire and were randomly allocated to either a depression or chronic back pain study condition. Measures of social exclusion through respondents' willingness to interact with hypothetical individuals, empathy and the Big Five personality traits were completed.

Results

Willingness to interact scores did not significantly differ depending on the diagnosis or sex of the hypothetical person in the vignette. For depression, higher levels of conscientiousness significantly predicted less willingness to interact. Whilst being a female participant and having higher empathy significantly predicted greater willingness to interact. For chronic back pain, higher empathy significantly predicted greater willingness to interact, with no significant predictors found from the Big Five personality traits.

Conclusion

Findings indicate that females and males with depression or chronic back pain face similar levels of social exclusion, with empathy being a core variable driving social exclusion behaviours. These findings enhance our understanding of potential variables driving social exclusion, in-turn informing campaign development to reduce public stigma towards depression and chronic back pain.

Stigma as a barrier to early intervention among youth seeking mental health services in Ontario, Canada: a qualitative study

BACKGROUND

Stigma associated with mental health challenges is a major barrier to service seeking among youth. Understanding how stigma impacts service-seeking decisions from the perspectives of youth remains underexplored. Such research is necessary to inform effective stigma reduction.

OBJECTIVE

This study aims to understand how stigma influences service seeking among youth with mental health challenges.

METHODS

Qualitative inquiry was taken using youth engagement, underpinned by pragmatism. Data were collected via 4 virtual focus groups with 22 purposively selected youth participants with lived experience of mental health challenges in Ontario, Canada. Focus group guides were developed collaboratively among research team members, including youth co-researchers. Data were analyzed inductively using reflexive thematic analysis.

RESULTS

Three main themes were constructed from the data: point of entry into the system, being biomedicalized or trivialized, and paving the way for non-stigmatizing services. Initial contact with the mental healthcare system was seen to be affected by stigma, causing participants to delay contact or be refused services if they do not fit with an expected profile. Participants described a constant negotiation between feeling 'sick enough' and 'not sick enough' to receive services. Once participants accessed services, they perceived the biomedicalization or trivialization of their challenges to be driven by stigma. Lastly, participants reflected on changes needed to reduce stigma's effects on seeking and obtaining services.

CONCLUSION

A constant negotiation between being 'sick enough' or 'not sick enough' is a key component of stigma from the perspectives of youth. This tension influences youth decisions about whether to seek services, but also service provider decisions about whether to offer services. Building awareness around the invisibility of mental health challenges and the continuum of wellness to illness may help to break down stigma's impact as a barrier to service seeking. Early intervention models of care that propose services across the spectrum of challenges may prevent the sense of stigma that deters youth from accessing and continuing to access services.

Quality of life among patients with obsessive compulsive disorder: Impact of stigma, severity of illness, insight, and beliefs

Background

No Indian studies have evaluated the impact of stigma, severity, and insight on the quality of life in obsessive compulsive disorder.

Methods

A hospital-based, cross-sectional, descriptive study on 100 patients of obsessive-compulsive disorder (OCD) as per Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, was conducted. Data were collected using socio-demographic performa, Yale-Brown obsessive-compulsive scale (Y-BOCS), WHOQoL-Bref hindi, hindi stigma scale, and Brown Assessment of Beliefs Scale (BABS) from March to June 2021. Appropriate statistical analyses were used.

Results

A majority of patients were males (58%), married (65%), above matric pass (89%), and belonged to rural areas (62%). The total stigma score showed a significant negative correlation with overall QoL (P < 0.01**), overall health (P < 0.002**), satisfaction with physical health (P 0.006**), psychological health (P < 0.01**), and social relations (P < 0.01**) on WHOQoL-Bref. Discrimination, disclosure, and positive aspect domains of the stigma scale also showed a significant negative correlation with many domains of QoL. Severity of illness showed a significant negative correlation with overall QoL (P 0.045*), satisfaction with physical health (P < 0.01**), psychological health (P 0.01**), social relations (P 0.004**), and environment (P 0.007**). Poorer insight on BABS was associated with poorer overall health (P 0.04*), satisfaction with physical health (P 0.001**), social relations (P 0.03**), and environment (P 0.009**). Stigma was significantly increased by higher severity of obsessions (P 0.04*), compulsions (P 0.007**), and total Y-BOCS score (P 0.007**).

Conclusion

Stigma and severity of OCD have a significant negative impact on quality of life. Stigma reduction and appropriate management of severity should be an integral part of management for patients with OCD.

Utility and validity of the Brief Psychiatric Rating Scale (BPRS) as a transdiagnostic scale

The Brief Psychiatric Rating Scale (BPRS) was originally conceived to assess psychopathology in several psychiatric disorders, making it an appropriate candidate to be used as a transdiagnostic instrument. We analyzed the utility and validity of the BPRS in a diagnostically heterogeneous sample of 600 psychiatric inpatients. As a comparator, we chose the mini-ICF-APP, a scale used to measure functioning and impairment across the diagnostic spectrum. Both scales had good internal consistency. The BPRS and the mini-ICF-APP showed a moderate correlation, with good levels of agreement. We were able to identify general symptoms present across the diagnostic spectrum, influencing severity and a cluster of symptoms specific for each diagnosis. Our results show the utility and validity of the BPRS as a transdiagnostic assessment tool that could easily be introduced in routine clinical work.

The Important Role of Stereotypes in the relation between Mental Health Literacy and Stigmatization of Depression and Psychosis in the Community

Increased mental health literacy (MHL) has not reduced stigmatization of people with mental disorder. Thus, we examined the role of stereotypes in the interplay of MHL (correct labelling, causal explanations) and the wish for social distance (WSD) from people with depressive and psychotic symptoms in a community sample of 1526 German-speaking participants in the Swiss 'Bern Epidemiological At-Risk' study (age 16-40 years; response rate: 60.1%). Following the presentation of an unlabelled case vignette of depression or psychosis, MHL, stereotypes and WSD were assessed in a questionnaire survey. Their interrelations were studied using structural equation modelling. MHL was not directly linked to WSD, only the psychosocial causal model was directly negatively associated with WSD. Perceived dangerousness particularly increased WSD, this was increased by a biogenetic causal model and decreased by a psychosocial causal model. Awareness-campaigns that, next to biological causes, emphasize psychosocial causes of mental disorders might better reduce stigmatization.

The disclosure dilemma: requesting accommodations for chronic pain in job interviews

PURPOSE

This study explores the job interview process for those who need disability-related accommodations on the job (in particular an "invisible" disability such as many of the long-term and late effects of cancer and its treatment (e.g., pain, fatigue, cognitive problems)), and explores whether the communication channel or the timing of the disclosure has implications on the perceived employability of applicants, with the aim of helping to close the employment gap for this marginalized population.

METHODS

Using 1917 participants in a partially crossed 2 × 3 × 2 experimental design, we explored disclosing the need for accommodations using each video or audio-only channels, by varying the timing of the disclosure within the interview (early, late, or not at all), and by varying the negotiation strategy used (modest or significant increase over proposed salary). Participants rated the candidate's employability at two different points in time.

RESULTS

Early and late disclosures of the need for accommodations were both associated with poorer ratings of employability. Disclosure via audio was singularly damaging as compared to video disclosure, whether it occurred early or late. Finally, asking for a significant increase in salary resulted in lower ratings of employability, especially if the disclosure of the disability happened late in the process (and proximally to the salary request itself).

CONCLUSIONS

Holding off on the request for accommodations until after the job has been offered may be advisable. Similarly, disability disclosures and requests for accommodation are better received using richer communication channels (video as opposed to audio). Salary requests are also sensitive topics and can be affected by ill-timed disclosures.

IMPLICATIONS FOR CANCER SURVIVORS

If accommodations are needed on the job (based on chronic pain), waiting until later in the process to discuss this topic (using video and not the phone) and ensuring distance in time from making a salary request are apparently the better choices.

Comparison of the Effects of a Genetic, a Mild Encephalitis, and a Psychosocial Causal Explanation of Schizophrenia on Stigmatizing Attitudes - a Pilot Study With a Quasi-Experimental Design

Background: Previous research has shown that the endorsement of biogenetic causal explanations of schizophrenia is associated with stronger stigmatizing attitudes against people with schizophrenia than the endorsement of psychosocial explanations. However, little is known about whether different biogenetic causal explanation beliefs differentially affect stigmatizing attitudes. This is particularly valid for the endorsement of the mild encephalitis hypothesis of schizophrenia. Aim: To examine to what extent different causal explanations of schizophrenia influence the desire for social distance from persons with schizophrenia. Methods: A study with a prospective, quasi-experimental design was carried out with students in Germany (N = 333). A case vignette depicting a person with schizophrenia-typical symptoms was presented, and a social distance scale (SDS) was used to measure the stigmatizing attitude against the person described. Participants were randomly assigned to one of three groups receiving different causal explanations of schizophrenia (genetic, mild encephalitis hypothesis, or psychosocial) without treatment information. Results: A one-way ANOVA showed that the mean SDS was lowest in the group with the mild encephalitis hypothesis explanation, followed by the genetic explanation group, and highest in the psychosocial explanation group. However, the differences between the groups were small and not significant. A subanalysis revealed a significant interaction between gender and causal explanation. Women showed a significantly lower desire for social distance than men when receiving the mild encephalitis hypothesis. Neither the study discipline nor the number of semesters of study had significant effects on the mean SDS. The differences between the mean SDS scores for the different items were much bigger than the differences for the different causal explanations. Regardless of the causal explanation, the extent of the desired social distance depends strongly on social proximity. Conclusion: The present study fits into previous research, which has found that biogenetic beliefs were either associated with more social distance or did not yield a statistically significant association. Although we found a small gender-specific effect of the endorsement of the mild encephalitis hypothesis, we do not recommend gender-specific anti-stigmatization campaigns because they might rightly raise suspicions of dishonesty and manipulation. Rather we support recovery-oriented messages focusing on effective treatments.

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.

The reMAP project: A retrospective, 15-year register study on inpatient care for youth with mental disorders

AIM

We aimed to characterize youth hospitalization trends in a psychiatric inpatient unit from a large, public university hospital with a broad catchment area in Milan, Italy.

METHODS

Hospitalization data of patients with an age at admission ≤ 35 were retrospectively retrieved over a time span of 15 years. The sample was comprised of 1982 admissions to a psychiatric ward, aggregated into ICD-10 diagnostic clusters and then analysed. We investigated the epidemiological trends with a focus on age at admission, gender, nationality and hospitalization rates, length of stay and "revolving door" readmissions within a year.

RESULTS

Hospitalization rates increased for eating Disorders and decreased for non-affective psychotic disorders; median length of stay generally decreased; hospitalization rates for foreign youth increased, in particular for those diagnosed with non-affective psychotic disorders, personality disorders, and substance-related and addictive disorders. The revolving door phenomenon was also associated with non-affective psychoses and neurodevelopmental disorders, while found to increase for eating disorders.

CONCLUSIONS

Hospitalization patterns reflect the general increase of foreign youth in the suburban tissue of a large metropolitan area like Milan. However, our data might underestimate the constant growth of mental health problems in foreign youth due to a generally lower access to services. Novel pharmacological treatments and early intervention programs might explain the decrease of hospitalization duration and hospitalization rate for youth with non-affective psychoses. The observed increase in hospitalization for young patients with eating disorders sustains the development of adequate policies tailored towards specialty wards.

Intersectionality and health-related stigma: insights from experiences of people living with stigmatized health conditions in Indonesia

Background

Health-related stigma is a complex phenomenon, the experience of which intersects with those of other adversities arising from a diversity of social inequalities and oppressive identities like gender, sexuality, and poverty – a concept called “intersectionality”. Understanding this intersectionality between health-related stigma and other forms of social marginalization can provide a fuller and more comprehensive picture of stigma associated with health conditions. The main objective of this paper is to build upon the concept of intersectionality in health-related stigma by exploring the convergence of experiences of stigma and other adversities across the intersections of health and other forms of social oppressions among people living with stigmatized health conditions in Indonesia.

Methods

This qualitative study interviewed 40 people affected by either of four stigmatizing health conditions (HIV, leprosy, schizophrenia, and diabetes) in Jakarta and West Java, Indonesia between March and June 2018. Data was analyzed thematically using an integrative inductive-deductive framework approach.

Results

The main intersectional inequalities identified by the participants were gender and socioeconomic status (n = 21), followed by religion (n = 13), age (n = 11), co-morbidity (n = 9), disability (n = 6), and sexuality (n = 4). Based on these inequalities/identities, the participants reported of experiencing oppression because of prevailing social norms, systems, and policies (macro-level), exclusion and discrimination from societal actors (meso-level), and self-shame and stigma (micro-level). While religion and age posed adversities that negatively affected participants in macro and meso levels, they helped mitigate the negative experiences of stigma in micro level by improving self-acceptance and self-confidence.

Conclusion

This study uncovered how the experience of health-related stigma intersects with other oppressions originating from the various social inequalities in an individual’s life. The findings highlight the importance of acknowledging and understanding the multi-dimensional aspect of lives of people living with stigmatized health conditions, and warrant integrated multi-level and cross-cutting stigma reduction interventions to address the intersectional oppressions they experience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01318-w.

Tensions and Paradoxes of Stigma: Discussing Stigma in Mental Health Rehabilitation

Mental illness remains as one of the most stigmatizing conditions in contemporary western societies. This study sheds light on how mental health professionals and rehabilitants perceive stigmatization. The qualitative study is based on stimulated focus group interviews conducted in five Finnish mental health rehabilitation centers that follow the Clubhouse model. The findings were analyzed through inductive content analysis. Both the mental health rehabilitants and the professionals perceived stigmatization as a phenomenon that concerns the majority of rehabilitants. However, whereas the professionals viewed stigma as something that is inflicted upon the mentally ill from the outside, the rehabilitants perceived stigma as something that the mentally ill themselves can influence by advancing their own confidence, shame management, and recovery. Improvements in treatment, along with media coverage, were seen as the factors that reduce stigmatization, but the same conceptualization did not hold for serious mental illnesses. As the average Clubhouse client was thought to be a person with serious mental illness, the rehabilitation context designed to normalize attitudes toward mental health problems was paradoxically perceived to enforce the concept of inevitable stigma. Therefore, it is important for professionals in rehabilitation communities to be reflexively aware of these tensions when supporting the rehabilitants.

Trajectories and mental health-related predictors of perceived discrimination and stigma among homeless adults with mental illness

Stigma and discrimination toward individuals experiencing homelessness and mental disorders remain pervasive across societies. However, there are few longitudinal studies of stigma and discrimination among homeless adults with mental illness. This study aimed to identify the two-year group trajectories of stigma and discrimination and examine the predictive role of mental health characteristics among 414 homeless adults with mental illness participating in the extended follow-up phase of the Toronto At Home/Chez Soi (AH/CS) randomized trial site. Mental health-related perceived stigma and discrimination were measured at baseline, one, and two years using validated scales. Group-based-trajectory modelling was used to identify stigma and discrimination group trajectory memberships and the effect of the Housing First treatment (rent supplements and mental health support services) vs treatment as usual on these trajectories. The associations between mental health-related characteristics and trajectory group memberships were also assessed using multinomial logistic regression. Over two-years, three group trajectories of stigma and discrimination were identified. For discrimination, participants followed a low, moderate, or increasingly high discrimination group trajectory, while for stigma, participants followed a low, moderate or high stigma group trajectory. The Housing First treatment had no significant effect on discrimination or stigma trajectories groups. For the discrimination trajectories, major depressive episode, mood disorder with psychotic features, alcohol abuse, suicidality, severity of mental health symptoms, and substance use severity in the previous year were predictors of moderate and increasingly high discrimination trajectories. History of discrimination within healthcare setting was also positively associated with following a moderate or high discrimination trajectory. For the stigma trajectories, substance dependence, high mental health symptoms severity, substance use severity, and discrimination experiences within healthcare settings were the main predictors for the moderate trajectory group; while substance dependence, suicidality, mental health symptom severity, substance use severity and discrimination experiences within health care setting were also positive predictors for the high stigma trajectory group. Ethno-racial status modified the association between having a major depression episode, alcohol dependence, and the likelihood of being a member of the high stigma trajectory group. This study showed that adults experiencing mental illness and homelessness followed distinct stigma and discrimination group trajectories based on their mental health-problems. There is an urgent need to increase focus on strategies and policies to reduce stigma and discrimination in this population.

The severity of psychiatric disorders

The issue of the severity of psychiatric disorders has great clinical importance. For example, severity influences decisions about level of care, and affects decisions to seek government assistance due to psychiatric disability. Controversy exists as to the efficacy of antidepressants across the spectrum of depression severity, and whether patients with severe depression should be preferentially treated with medication rather than psychotherapy. Measures of severity are used to evaluate outcome in treatment studies and may be used as meaningful endpoints in clinical practice. But, what does it mean to say that someone has a severe illness? Does severity refer to the number of symptoms a patient is experiencing? To the intensity of the symptoms? To symptom frequency or persistence? To the impact of symptoms on functioning or on quality of life? To the likelihood of the illness resulting in permanent disability or death? Putting aside the issue of how severity should be operationalized, another consideration is whether severity should be conceptualized similarly for all illnesses or be disorder specific. In this paper, we examine how severity is characterized in research and contemporary psychiatric diagnostic systems, with a special focus on depression and personality disorders. Our review shows that the DSM-5 has defined the severity of various disorders in different ways, and that researchers have adopted a myriad of ways of defining severity for both depression and personality disorders, although the severity of the former was predominantly defined according to scores on symptom rating scales, whereas the severity of the latter was often linked with impairments in functioning. Because the functional impact of symptom-defined disorders depends on factors extrinsic to those disorders, such as self-efficacy, resilience, coping ability, social support, cultural and social expectations, as well as the responsibilities related to one's primary role function and the availability of others to assume those responsibilities, we argue that the severity of such disorders should be defined independently from functional impairment.

Attitudes towards severe mental illness and social distance: A survey of volunteer befrienders in Austria

BACKGROUND

Research suggests there is a propensity for people in the general population to distance themselves from people with severe mental illness (SMI), which reportedly decreases with increased contact with individuals with SMI. Volunteer befrienders in the mental health sector have ongoing contact with this population, yet little data exist to reflect their attitudes towards people with SMI.

METHOD

A questionnaire was distributed to all volunteer befrienders for people with SMI within volunteering programmes organised in five Austrian regions. A vignette described an individual with SMI and was followed by questions assessing willingness to interact with this person in personal or professional contexts. Social distance scores, calculated based on responses to attitude items, were used as the dependent variable in regression analyses. Independent variables included participant characteristics, experience of family/friends with mental illness, time spent befriending and satisfaction with the relationship.

RESULTS

Questionnaires were completed and returned by 360 volunteers (54.0%). A minority would allow someone with SMI to look after their children (6.2%), while most volunteers positively endorsed other personal interactions such as having the individual marry into their family (67.8%) or become a neighbour (99.7%). Social distance ( M = 2.5, standard deviation [ SD] = 1.16) was not associated with any independent variables.

CONCLUSIONS

Volunteers had a lower desire for social distance from individuals with SMI as compared to findings from the general population. Future research may establish whether lower social distance is part of the motivation to volunteer as a befriender to people with severe mental illness or develops over time in that role or both.

Measuring Recurring Stigma in the Lives of Individuals with Mental Illness

We present an exploratory factor analysis of the 8-item Daily Indignities of Mental Illness (DIMI) scale, created to measure the detection and perceptions of recurring stigma among individuals with recent psychiatric hospitalizations. Structured in-person interviews were conducted with individuals with recent psychiatric hospitalizations in metropolitan New York. The 8-item DIMI scale's internal consistency for the sample (n = 65), measured by Cronbach's alpha, was 0.869. Statistically significantly higher DIMI scale scores were observed among individuals with more than 2 psychotic episodes and those reporting seeing relatives less often after hospitalization. The DIMI scale possesses good internal consistency for research contextualizing perceptions around the occurrence or recurrence of mental illness-related stigma among individuals with recent psychiatric hospitalizations.

Different faces of discrimination: perceived discrimination among homeless adults with mental illness in healthcare settings

BACKGROUND

Research on discrimination in healthcare settings has primarily focused on health implications of race-based discrimination among ethno-racial minority groups. Little is known about discrimination experiences of other marginalized populations, particularly groups facing multiple disadvantages who may be subjected to other/multiple forms of discrimination.

OBJECTIVES

(1) To examine the prevalence of perceived discrimination due to homelessness/poverty, mental illness/alcohol/drug related problems, and race/ethnicity/skin color while seeking healthcare in the past year among racially diverse homeless adults with mental illness; (2) To identify whether perceiving certain types of discrimination is associated with increased likelihood of perceiving other kinds of discrimination; and (3) To examine association of these perceived discrimination experiences with socio-demographic characteristics, self-reported measures of psychiatric symptomatology and substance use, and Emergency Department utilization.

METHODS

We used baseline data from the Toronto site of the At Home/Chez Soi randomized controlled trial of Housing First for homeless adults with mental illness (n = 550). Bivariate statistics and multivariable logistic regression models were used for the analysis.

RESULTS

Perceived discrimination related to homelessness/poverty (30.4%) and mental illness/alcohol/substance use (32.5%) is prevalent among ethnically diverse homeless adults with mental illness in healthcare settings. Only 15% of the total participants reported discrimination due to race/ethnicity/skin color. After controlling for relevant confounders and presence of psychosis, all types of discrimination in healthcare settings were associated with more frequent ED use, a greater - 3 - severity of lifetime substance abuse, and mental health problems. Perceiving discrimination of one type was associated with increased likelihood of perceiving other kinds of discrimination.

CONCLUSIONS

Understanding the experience of discrimination in healthcare settings and associated healthcare utilization is the first step towards designing policies and interventions to address health disparities among vulnerable populations. This study contributes to the knowledge base in this important area.

TRIAL REGISTRATION NUMBER

This study has been registered with the International Standard Randomized Control Trial Number Register and assigned ISRCTN42520374.

Fatigue as prognostic risk marker of mental sickness absence in white collar employees

PURPOSE

To investigate fatigue as prognostic risk marker for identifying working employees at risk of long-term sickness absence (SA).

METHODS

At baseline, fatigue was measured in 633 white collar employees with the checklist individual strength (CIS) including scales for fatigue severity, reduced concentration, reduced motivation, and reduced physical activity. SA was medically certified by an occupational physician in the 3rd or 4th SA week with diagnostic codes according to the 10th version of the International Classification of Diseases. Medically certified SA was retrieved at the individual level from an occupational health register after 1-year follow-up. CIS scores were investigated as prognostic risk markers predicting medically certified SA and particularly SA certified as mental SA.

RESULTS

614 employees (N = 378 men and N = 236 women) had complete data and were eligible for analysis; 63 (10 %) had medically certified SA of whom 39 (6 %) had mental SA. Fatigue severity and total CIS scores were associated with medically certified SA in men, but poorly discriminated between men with and without medically certified SA. Fatigue severity, reduced concentration, reduced motivation, and total CIS scores were also associated with mental SA in men. CIS and its reduced concentration scale were valid prognostic risk markers of mental SA. CONCLUSION Fatigue was a prognostic risk marker of mental SA in white collar men. The CIS should be further validated as a screening tool for the risk of mental SA in white collar working populations.

Too sick, not sick enough? Effects of treatment type and timing on depression stigma

A case vignette survey design was used to explore effects of treatment timing (early, delayed, or untreated) and depression treatment type (pharmacological or psychological) on components of depression stigma. The survey was distributed to two samples, 116 undergraduates (UGs) and 301 participants from the online service Amazon Mechanical Turk. As expected, extended untreated depression was associated with greater social distance and negative character evaluation than treated depression, and early treatment was associated with higher illness invalidity stigma (both samples) and illness responsibility stigma (UG sample only). Interaction effects suggested that pharmacotherapy, in comparison with psychotherapy, was more sensitive to the effects of treatment timing on stigma. Taken together, the pattern of results suggests that separate facets of stigma are associated with early depression treatment and prolonged untreated depression. Evidence for separate stigmatization of early treatment and extended illness holds important implications for antistigma campaigns.

Chances and risks of predicting psychosis

Prevention is currently regarded a promising strategy for fighting the unfavorable consequences of psychosis. Yet, for the error probability inherent in any predictive approach, benefits and costs must be carefully weighed against each other. False attribution of risk may unnecessarily provoke stress and anxiety, and lead to unwarranted intervention exposure. However, clinical risk samples already exhibit psychopathological symptoms, cognitive and functional impairments, and help-seeking for mental problems. Thus, the risk of futile interventions is low as long as preventive measures also provide treatment for current complaints. Differentiation between still normal and clinically relevant mental states is another challenge as psychotic-like phenomena occur frequently in the general population, especially in younger adolescents. Reported prevalence rates vary with age, and if severe in terms of frequency and persistence, these phenomena considerably increase risk of psychosis in clinical as well as general population samples. Stigmatization is another concern, though insufficiently studied. Yet, at least more severe states of risk, which are accompanied by changes in thinking, feeling, and behavior, might lead to unfavorable, (self-) stigmatizing effects already by themselves, independent of any diagnostic "label," and to stress and confusion for the lack of understanding of what is going on. To further improve validity of risk criteria, advanced risk algorithms combining multi-step detection and risk stratification procedures should be developed. However, all prediction models possess a certain error probability. Thus, whether a risk model justifies preventive measures can only be decided by weighing the costs of unnecessary intervention and the benefits of avoiding a potentially devastating outcome.

Stigma experiences in bipolar patients: the impact upon functioning

The aim of this study was to investigate the impact of self-rated stigma and functioning in patients with bipolar disorder in South Brazil. This is a cross-sectional study. Sixty participants with bipolar disorder were recruited from an outpatient Bipolar Disorder Program. Experiences with and impact of perceived stigma were evaluated using the Inventory of Stigmatizing Experiences. Functional impairment was assessed with the Functioning Assessment Short Test (FAST). Higher scores of self-perceived stigma were correlated with higher FAST scores, indicating more disability. After linear correlation analysis, current depressive symptoms, age at onset of treatment, age at diagnosis and functioning were correlated with self-perceived stigma. The study demonstrated a correlation between stigma and poor functioning in bipolar disorder. Perceived stigma is really important to individuals with bipolar disorder, both to how they experience their illness and to its results on functioning. Potential consequences of such results for mental health care professionals are discussed. Differential clinical features, sociocultural factors and the sample size limit the generalization of the present findings.

The influence of stigma on young people's help-seeking intentions and beliefs about the helpfulness of various sources of help

PURPOSE

In this study, we examined whether young people's help-seeking intentions and beliefs about the helpfulness of various sources of help are influenced by their own, and their parents' stigmatising attitudes towards young people with mental disorders.

METHODS

A national telephone survey was conducted with 3,746 Australians aged 12-25 years and 2,005 of their parents. Stigmatising attitudes, help-seeking intentions, and perceived helpfulness of various sources of help were assessed in relation to four vignettes of a young person with a mental disorder (psychosis, depression, depression with alcohol misuse or social phobia).

RESULTS

Unlike 'stigma perceived in others', the 'weak-not-sick', 'social distance' and 'dangerous/unpredictable' dimensions of young people's stigma were associated with both help-seeking intentions and helpfulness beliefs about various sources of help. Attributing mental disorder to a personal weakness rather than an illness was associated with less intention to seek help from a doctor and less positive beliefs about professional sources (including doctors, counsellors, and psychologists). In contrast, young adults aged 18-25 years who perceived the vignette character as more dangerous or unpredictable had greater intention to seek help from a psychiatrist and a helpline, and more positive beliefs about psychiatrists. Greater social distance was associated with less intention to seek help from informal sources and less positive beliefs about these sources. No consistent pattern of associations was found for parent stigma.

CONCLUSIONS

The findings suggest that different dimensions of youth stigma differentially influence help-seeking intentions and beliefs about the helpfulness of different sources of help.

Differences in self-reported importance of elements of health and subjectively experienced health among outpatients in community mental health services

Positive dimensions of mental health are strong protective factors against physical and mental illness in general population. A cross-sectional study including a randomly selected sample of 141 outpatients was performed to explore differences in patients' self-reported importance of elements of health and subjective experiences of health related to sociodemographic background variables. The examination of differences in self-reported importance of elements of health showed differences regarding gender, and the analyses of subjectively experienced health showed differences regarding age and diagnosis. Clinical interventions aiming at strengthening positive dimensions of health are required in community mental health services to meet the patients' individual needs of enhanced health.

"Mad, sick, head nuh good": mental illness stigma in Jamaican communities

Stigma may be an important factor in mental health service seeking and utilization. However, little work on stigma has been conducted in developing nations in the Caribbean, including Jamaica. We explored mental illness stigma in Jamaica by conducting focus groups with 16 community samples. Four overarching conceptual themes are discussed: (1) community members' definitions of stigma; (2) emotional responses towards those with mental illness, such as fear and love; (3) behavioral responses towards those with mental illness, including avoidance and cautious approach; and (4) perceptions of and beliefs about mental illness, including a distinction between "madness" and "mental illness."

Attitudes towards people with mental disorders: the psychometric characteristics of a Finnish questionnaire

BACKGROUND

The prevalence of mental disorders, especially depression, increasingly creates concern for our mental, social and economic well-being. The public has insufficient knowledge about mental disorders and their treatment. A stigma is attached to mental disorders, which has a multifaceted impact on the lives of patients and their families. A Finnish general population survey studied knowledge of and attitudes towards mental health problems. This study examines the background dimensions of the attitude items used in the survey.

METHODS

An eight-page health survey questionnaire with 16 items on attitudes to mental health and depression was sent to a randomly selected sample of 10,000 persons aged 15-80 years. The overall response rate was 55.2%. The data were submitted to a principal component analysis (PCA). Two components were extracted by means of this analysis and submitted to further reliability analyses as well as to a preliminary validity analysis.

RESULTS

The PCA identified four components: (1) depression is a matter of will, (2) mental problems have negative consequences, (3) one should be careful with antidepressants and (4) you never recover from mental problems.

CONCLUSION

The internal consistencies of the first two components were sufficient to build dimension scales for future analyses. The extracted components fit consistently with the leading stigma theories and earlier studies measuring public attitudes.

Perceived stigma among individuals with common mental disorders

BACKGROUND

Severe mental disorders are associated with social distance from the general population, but there is lack of data on the stigma reported by individuals with common mental disorders.

AIMS

To identify the correlates and the impact of stigma among individuals with common mental disorders.

METHODS

Cross-sectional, household interview survey of 8796 representing the non-institutionalized adults of Belgium, France, Germany, Italy, the Netherlands and Spain. Two perceived stigma questions (embarrassment and discrimination) were asked to respondents with significant disability. Health-related quality of life measured by the SF-12, work and activity limitation and social limitation were also assessed.

RESULTS

Among the 815 participants with a 12-month mental disorder and significant disability, 14.8% had perceived stigma. Stigma was significantly associated with low education, being married/living with someone and being unemployed. Perceived stigma was associated with decreased quality of life (SF-12 PCS score -4.65; p<0.05), higher work and role limitation and higher social limitation.

CONCLUSION

Individuals with mental disorders are more likely to report stigma if they have lower education, are married, or are unemployed. Perceived stigma is associated with considerably decrease in quality of life and role functioning. Health professionals and society at large must be aware of these findings, which suggest that fighting stigma should be a public health priority.

Empathy in schizophrenia: impaired resonance

Resonance is the phenomenon of one person unconsciously mirroring the motor actions as basis of emotional expressions of another person. This shared representation serves as a basis for sharing physiological and emotional states of others and is an important component of empathy. Contagious laughing and contagious yawning are examples of resonance. In the interpersonal contact with individuals with schizophrenia we can often experience impaired empathic resonance. The aim of this study is to determine differences in empathic resonance-in terms of contagion by yawning and laughing-in individuals with schizophrenia and healthy controls in the context of psychopathology and social functioning. We presented video sequences of yawning, laughing or neutral faces to 43 schizophrenia outpatients and 45 sex- and age-matched healthy controls. Participants were video-taped during the stimulation and rated regarding contagion by yawning and laughing. In addition, we assessed self-rated empathic abilities (Interpersonal Reactivity Index), psychopathology (Positive and Negative Syndrome Scale in the schizophrenia group resp. Schizotypal Personality Questionnaire in the control group), social dysfunction (Social Dysfunction Index) and executive functions (Stroop, Fluency). Individuals with schizophrenia showed lower contagion rates for yawning and laughing. Self-rated empathic concern showed no group difference and did not correlate with contagion. Low rate of contagion by laughing correlated with the schizophrenia negative syndrome and with social dysfunction. We conclude that impaired resonance is a handicap for individuals with schizophrenia in social life. Blunted observable resonance does not necessarily reflect reduced subjective empathic concern.

Prevalence and correlates of poor medication adherence amongst psychiatric outpatients in southwestern Nigeria

OBJECTIVE

The aim of this study was to assess the rate of adherence to medications amongst psychiatric outpatients in Nigeria and examine factors associated with medication nonadherence amongst this group.

METHOD

Psychiatric outpatients (n=342) from three centres were assessed for medication adherence using the Morisky Medication Adherence Questionnaire. Details regarding sociodemographic variables (age, sex, education, religion, marital status, employment, income, medication cost), illness related variables (diagnosis, duration, number of episodes/admissions, insight, severity of symptoms, mental state, functional status), medication related variables (type, mode of administration, side effect, attitude to medication) and perception related variables (self-stigma, perceived causation and prognosis) were also obtained.

RESULTS

There were 76 participants (22.2%) with good medication adherence, 102 (29.8%) with moderate adherence and 164 (48.0%) with poor adherence. The significant independent correlates of poor medication adherence included being employed [odds ratio (OR) 3.42, 95% confidence interval (95% CI) 2.17-5.39], poor social support (OR 5.86, 95% CI 2.87-12.17), high self-stigma (OR 4.70, 95% CI 2.24-9.96) and perceived spiritual causation of mental illness (OR 3.74, 95% CI 1.87-7.74).

CONCLUSIONS

The majority of psychiatric outpatients in southwestern Nigeria had poor medication adherence. Our findings stressed the importance of patients' perception and social environment in determining treatment adherence and the necessity of educating the patient. Clinicians' attention to psychological barriers early in treatment may improve medication adherence and ultimately affect the course of illness.

Interlocking oppressions: the effect of a comorbid physical disability on perceived stigma and discrimination among mental health consumers in Canada

People living with mental health problems often face stigma and discrimination; however, there is a lack of research that examines how comorbid conditions affect this perceived stigma. This study sought to determine whether people who have a comorbid physical and psychiatric disability experience more stigma than those with only a psychiatric disability. It also looked at how perceived stigma and discrimination affect physical and mental health. A secondary analysis on data from interviews with 336 former and current clients of the mental health system in a mid-size Canadian city in 2005 was performed. Of these, 203 (60.4%) reported they had a psychiatric disability, 112 (33.0%) reported that they had a physical disability, with 74 reporting both a psychiatric and a physical disability. People with a self-reported psychiatric disability and a self-reported comorbid physical disability faced more overall perceived discrimination/stigma (P = 0.04), than those with a psychiatric disability alone. Perceived discrimination/stigma was positively correlated with psychiatric problem severity (P = 0.02), and negatively correlated with self-rated general health (P < 0.001), physical condition (P < 0.001), emotional well-being (P < 0.001) and life satisfaction (P < 0.001). These results bring to light the aggravating effect of a physical disability on the perceived stigma for those living with a mental illness, and also strengthen the knowledge that stigma and discrimination have a negative impact on health. Healthcare providers should recognise this negative impact and screen for these comorbid conditions. Policy-makers should take measures such as improving access to housing and employment services to help reduce stigma and discrimination against this particularly vulnerable group.

Depression self-stigma: a new measure and preliminary findings

It is widely recognized that stigmatization of mental disorders leads stigmatized individuals to avoid treatment altogether or discontinue treatment prematurely. Literature suggests that the impact of stigma may differ by diagnosis; however, previous attempts to measure self-stigma have not been disorder specific. This study sought to develop the Depression Self-Stigma Scale (DSSS) and identify distinct constructs associated with depression self-stigma. Items for the initial administration of the DSSS were developed through careful review of existing measures and the literature on stigma and depression. Items were administered to undergraduates and community members with self-reported depression (N = 391). Results indicated 5 factors (general self-stigma, secrecy, public stigma, treatment stigma, and stigmatizing experiences) with good factor structure, internal consistency, and evidence for construct validity.

Five-year follow-up during antipsychotic treatment: efficacy, safety, functional and social outcome

OBJECTIVE

Explore the long-term course of schizophrenia and related disorders.

METHOD

Naturalistic study of 225 patients initially treated with risperidone (monotherapy or in combination with other psychotropic drugs) over 5 years.

RESULTS

Stable symptomatology and side effects were observed. Clinician GAF scores were 55-61, but patients' self-ratings were higher. Clinician and patient CGI scores were at the same level. Annual in-patient days decreased but days in sheltered accommodations increased still more. Only 12% of the patients studied or worked full-time. One in four had no social contacts except with staff. Eight patients died during the 5 years.

CONCLUSION

The findings underline the chronicity and seriousness of psychotic disorders in terms of social outcome and, indirectly, the low quality of life of this group of persons. Patients were generally well aware of their illness and able to sort out symptoms from drug side effects. This opens for more active involvement of patients in monitoring their own treatment.

Between health care and social security--psychiatric patients and the disability pension system in Norway and Russia

BACKGROUND

The official statistics of persons with mental disorders who are granted disability pension (DP) in Russia and Norway indicate large differences between the countries.

METHODS

This qualitative explorative hypothesis-generating study is based on text analysis of the laws, regulations and guidelines, and qualitative interviews of informants representing all the organisational elements of the DP systems in both countries.

RESULTS

The DP application process is initiated much later in Norway than in Russia, where a 3 year occupational rehabilitation and adequate treatment is mandatory before DP is granted. In Russia, two instances are responsible for preparing of the medical certification for DP, a patients medical doctor (PD) and a clinical expert commission (CEC) while there is one in Norway (PD). In Russia, the Bureau of Medical-Social Expertise is responsible for evaluation and granting of DP. In Norway, the local social insurance offices (SIO) are responsible for the DP application. Decisions are taken collectively in Russia, while the Norwegian PD and SIO officer often take decisions alone. In Russia, the medical criterion is the decisive one, while rehabilitation and treatment criteria are given priority in Norway. The size of the DP in Norway is enough to cover of subsistences expenditure, while the Russian DP is less than the level required for minimum subsistence.

CONCLUSION

There were noteworthy differences in the time frame, organisation model and process leading to a DP in the two countries. These differences may explain why so few patients with less severe mental disorders receive a DP in Russia. This fact, in combination with the size of the DP, may hamper reforms of the mental health care system in Russia.

Stigma and mental health professionals: a review of the evidence on an intricate relationship

In the past decade, mental health professionals have initiated a number of national and international efforts against the stigma of mental illness. While largely successful in beating stigma and discrimination, these programmes have, in part, been criticized to be largely uninformed by the lived realities of people with mental illness and their families. Some critics claimed that anti-stigma efforts led by mental health professionals were in fact a concealed attempt at de-stigmatizing psychiatry itself as a profession. This paper will attempt to throw light on the various ways in which mental health professionals are 'entangled' in anti-stigma activities. It will outline the complex relationships between stigma and the psychiatric profession, presenting evidence on how its members can simultaneously be stigmatizers, stigma recipients and powerful agents of de-stigmatization. In exploring the role of mental health professionals as targets of stigma, new findings will be presented on the role of stigma as a professional stressor in psychiatry. Conclusions will be drawn on how the pursuit of professional self-interest can be a legitimate goal of anti-stigma programmes. Further, ways in which acknowledging psychiatry's own agenda can contribute to both credibility and success of fighting stigma from within psychiatry will be discussed.

Stigmatization, social distance and exclusion because of mental illness: the individual with mental illness as a 'stranger'

The stigma attached to mental illness often leads to underestimation, underdiagnosis and undertreatment of mental disorders. A lack of knowledge of causes, symptoms and treatment options of mental disorders in the public and a lack of personal contact with affected individuals can result in prejudices and negative attitudes towards them-and subsequently in stigmatization and discrimination. Human beings suffering from mental illness often are recognized as 'strangers'. But, social-psychological and philosophical analysis of the recognition of 'strangeness' in mentally ill individuals as one of the main predictors for social distance towards them, shows, that the other person only remains a stranger if the available cognitive patterns of interpretation fail. Society must provide the people living in it with the interpretational patterns to take away the recognized strangeness from mentally ill persons and thus making him, or her, an accepted other member.

The stigma of mental illness: anticipation and attitudes among patients with epileptic, dissociative or somatoform pain disorder

The aim of this study was to survey the attitudes of 101 consecutive in- and out-patients with epileptic, dissociative or somatoform pain disorders (mean age: 43 [+/-11] years; 58% female) from either the Department of Psychiatry or Neurology toward anticipated mental illness stigma. The patients were administered a modified 12-item version of Links Stigma Questionnaire. Nearly 60% of all 101 patients believe that "most people" would not allow a mental patient "to take care of their children", "most young women" would be "reluctant to date a man" who has been treated for a mental illness and "most employers would pass over" the application of a psychiatric patient in favour of another applicant. Fifty five percent of the respondents assume that "most people think less of a person who has been in a mental hospital" and over a half of all patients interviewed assert that the general population thinks that psychiatric patients are "less intelligent, less trustworthy and that their opinion is taken less seriously by others". Gender, age and education had no influence on the overall results. There is a high stigmatisation concerning psychiatry even in patients with epilepsy and somatoform/dissociative symptoms with psychiatric comorbidity. Fear of being stigmatized is more pronounced among somatoform pain patients as compared to patients suffering from epileptic or dissocative disorders, with particular reference to close personal relationships.