Mental-health-related stigma among Japanese children and their parents and impact of renaming of schizophrenia

Impact, feasibility, and acceptability of CREATORS: An arts-based pilot intervention to reduce mental-health-related stigma among youth in Hyderabad, India

Background

Mental-health-related stigma prevents youth from seeking help for mental health problems. Limited studies in low- and middle-income countries assess the effect of arts-based education in reducing such stigma among youth, thereby leaving a gap in evidence-based, age- and culturally-appropriate interventions.

Objective

To evaluate the impact, feasibility, and acceptability of CREATORS, an arts-based educational program on reducing mental-health-related stigma among youth in India.

Methods

We conducted a mixed-methods, pre-post control group study among college-going adolescents in Hyderabad, India. At baseline and post-intervention (after six weeks), we examined differences in intended behavior towards people with mental health problems.

Results

Our study involved 432 participants across three study groups: participants creating art on the theme of mental-health-related stigma over six weeks (n = 123), a student audience viewing 2-h arts show by participants (n = 244), and a control group (n = 65). Between baseline and post-test, participants creating art showed significantly lower stigma towards people with mental health problems compared to members of the control group (coefficient = 1.55, 95%CI 0.06-3.04, p = 0.041). Participants found the intervention useful and enjoyable (>95%; n = 773 across six weeks). Participants identified that collaborative creation of art made the subject of mental health interesting and relatable.

Conclusions

Participating in an arts-based educational program was associated with significantly lower mental-health-related stigma among youth compared to a control group in the short term. High acceptability of the program demonstrates the utility of arts-based education to address mental-health-related stigma. With community partners and artists as facilitators, our program may support mental health specialists in mental health promotion.

The impact of renaming schizophrenia on destigmatization: The Asian experience

The term "schizophrenia" can indeed carry stigmatizing connotations. Proposals to rename schizophrenia have emerged as a potential strategy to alleviate this stigma, but the impact of such a change is not yet fully understood. In several Asian countries that have adopted a new name for schizophrenia, there is evidence that renaming is associated with improved attitudes towards individuals with schizophrenia and an increased willingness to disclose diagnoses. However, the portrayal of schizophrenia in the media seems unaffected by these name changes. In other countries where "schizophrenia" is still the standard term, alternative names have been suggested, but research on their effectiveness in reducing stigma shows mixed results. Mental health professionals frequently support a name change, recognizing the term's negative implications. However, it is crucial to recognize that a mere semantic revision, devoid of substantial conceptual alterations, may only offer a temporary decrease in stigma. Thus, renaming schizophrenia, coupled with a re-conceptualization of the disorder, may be a constructive step toward reducing its stigmatization.

Family influence on stigma internalisation in people with severe mental illness: A grounded theory study

The internalisation of stigma has adverse effects on the recovery and quality of life of people with severe mental illnesses. Studies have shown that life experiences in one's close environment are highly relevant in explaining the onset and development of self-stigma. Families play a critical role in the daily care of people with severe mental illness and have a profound impact on patient recovery. This qualitative study explored the influence of family on stigma internalisation among people with severe mental illness in the context of Chinese culture. A grounded theory design was used. Semi-structured interviews were conducted with 20 patients with severe mental illness and 10 family members, and observations were carried out among five of the families. The data analysis followed three steps (open, axial and selective coding) and involved the use of a constant comparative method and memo writing. The COREQ reporting checklist was used to report the results. Our findings revealed that families can facilitate and impede stigma internalisation in people with severe mental illness via negative or positive daily interactions. A theoretical framework was developed to present the potential effects of the identified family factors on stigma internalisation. Three major family factors influencing patients' internalised stigma were identified, namely, "beliefs of family members" at the individual level, "responses within the family" at the intrafamilial level and "differentiated family environment" at the level of the whole family system, in which "biased beliefs of family members" could bring about "negative responses within the family" and further result in patients' internalised stigma. Our findings suggested that mental health stigma internalised by ill people should be viewed within the broad context of the family. Family-based programs aimed at improving positive interactions and support within the family need to be developed and launched, with particular attention given to interventions for affiliate stigma, coping with stigma and families' negative responses towards people with severe mental illness to prevent the internalisation of stigma by patients.

Nomenclature for psychosis risk in Japan: Survey results from high-risk individuals, caregivers, and mental health professionals

BACKGROUND

Labeling terms for high-risk state for psychosis, such as 'ultra-high risk' (UHR), 'attenuated psychosis syndrome' (APS), and 'at-risk mental state' (ARMS), have been criticized for their potential to lead to stigma. Hence, mental health service users in Melbourne recently proposed new terms illustrating the at-risk concept ['pre-diagnosis stage' (PDS), 'potential of developing a mental illness' (PDMI), and 'disposition for developing a mental illness' (DDMI)]. We aimed at testing the suitability of these existing and new terms in the clinical settings of early psychiatric intervention in Japan.

METHODS

At two centers of early intervention (Toyama and Tokyo), a questionnaire on the understanding and opinion of high-risk terminology was administered to 62 high-risk patients, 44 caregivers, and 64 clinicians. The questionnaire contained the existing and new terms, where the term ARMS was translated into two different Japanese terms ARMS-psychosis and ARMS-kokoro. Participants' opinion on the disclosure of high-risk status was also obtained.

RESULTS

ARMS-kokoro was most preferred, least stigmatizing, and best explaining the patients' difficulties for all groups, while UHR and other terms including the Japanese word 'psychosis' (i.e., APS and ARMS-psychosis) were not preferred. New labeling terms were generally not well received. All groups preferred full disclosure of high-risk terms by the psychiatrist with or without the presence of family members.

CONCLUSION

The term ARMS-kokoro was commonly accepted as a favorable labeling term for the high-risk state for psychosis in Japan. However, another translation ARMS-psychosis was considered stigmatizing, demonstrating the importance of appropriate translation of high-risk terminology into local languages.

Linguistic and (micro)cultural differences in the global debate about re-naming 'schizophrenia': A mixed-methods survey from Switzerland

BACKGROUND AND HYPOTHESIS

This survey explores Swiss mental health professionals', users', and relatives' opinions on re-naming schizophrenia exploiting Switzerland's specific multilingualism to examine possible effects of linguistic and microcultural differences on the issue.

STUDY DESIGN

Opinions on 'schizophrenia' were collected using a self-rated online questionnaire incl. Freetext answers available in the three main Swiss languages, German, French and Italian. It was distributed to the main professional and self-help organizations in Switzerland between June and October 2021.

STUDY RESULTS

Overall, 449 persons completed the questionnaire, 263 in German, 172 in French and 14 in Italian. Of the total sample, 339 identified as mental health professionals, 81 as relatives and 29 as users. Considering the whole sample, almost half favored a name-change with a significant difference between stakeholder- and between language groups. Also, the name 'schizophrenia' was evaluated more critically than the diagnostic concept. Qualitative analysis of freetext answers showed a highly heterogenous argumentation, but no difference between language groups.

CONCLUSIONS

Our results suggest the attitude towards re-naming might itself be subject to (micro)cultural difference, and they highlight the nature of 'schizophrenia' as not only a scientific, but also a linguistic and cultural object. Such local factors ought to be taken into consideration in the global debate.

Schizophrenia: A Narrative Review of Etiopathogenetic, Diagnostic and Treatment Aspects

Although schizophrenia is currently conceptualized as being characterized as a syndrome that includes a collection of signs and symptoms, there is strong evidence of heterogeneous and complex underpinned etiological, etiopathogenetic, and psychopathological mechanisms, which are still under investigation. Therefore, the present viewpoint review is aimed at providing some insights into the recently investigated schizophrenia research fields in order to discuss the potential future research directions in schizophrenia research. The traditional schizophrenia construct and diagnosis were progressively revised and revisited, based on the recently emerging neurobiological, genetic, and epidemiological research. Moreover, innovative diagnostic and therapeutic approaches are pointed to build a new construct, allowing the development of better clinical and treatment outcomes and characterization for schizophrenic individuals, considering a more patient-centered, personalized, and tailored-based dimensional approach. Further translational studies are needed in order to integrate neurobiological, genetic, and environmental studies into clinical practice and to help clinicians and researchers to understand how to redesign a new schizophrenia construct.

Personalized values in life as point of interaction with the world: Developmental/neurobehavioral basis and implications for psychiatry

Behavioral neuroscience has dealt with short-term decision making but has not defined either daily or longer-term life actions. The individual brain interacts with the society/world, but where that point of action is and how it interacts has never been an explicit scientific question. Here, we redefine value as an intrapersonal driver of medium- and long-term life actions. Value has the following three aspects. The first is value as a driving force of action, a factor that commits people to take default-mode or intrinsic actions daily and longer term. It consists of value memories based on past experiences, and a sense of values, the source of choosing actions under uncertain circumstances. It is also a multilayered structure of unconscious/automatic and conscious/self-controlled. The second is personalized value, which focuses not only on the value of human beings in general, but on the aspect that is individualized and personalized, which is the foundation of diversity in society. Third, the value is developed through the life course. It is necessary to clarify how values are personalized through the internalization of parent-child, peer, and social experiences through adolescence, a life stage almost neglected in neuroscience. This viewpoint describes the brain and the behavioral basis of adolescence in which the value and its personalization occur, and the importance of this personalized value as a point of interaction between the individual brain and the world. Then the significance of personalized values in psychiatry is discussed, and the concept of values-informed psychiatry is proposed.

Exploring Empathy and Compassion Using Digital Narratives (the Learning to Care Project): Protocol for a Multiphase Mixed Methods Study

BACKGROUND

Digital stories-first-person, self-made, 2- to 3-minute videos-generate awareness, impart knowledge, and promote understanding on topics such as mental illness. Digital stories are a narrative-based art form often created by individuals without formal training in filmmaking to relate personal experiences. Somewhat like digital narratives, video testimonies created within the social marketing or fundraising campaigns of government agencies and private or public corporations aim to reduce the stigma of mental illness while supporting research and services. In video testimonies, personal stories are captured on camera by professional filmmakers. Sharing critical life events greatly benefits tellers and listeners alike, supporting catharsis, healing, connectiveness, and citizenship.

OBJECTIVE

This study explores digital stories and video testimonies featuring mental illness and recovery in their ability to elicit empathy and compassion while reducing stigma among viewers.

METHODS

Using mixed methods, phase 1 will involve a search of Canadian social marketing activities and fundraising campaigns concerning mental illness and recovery. Phase 2 will involve the organization of digital storytelling workshops in which participants will create digital stories about their own experiences of mental illness and recovery. In phase 3, a pilot randomized controlled trial will be undertaken to compare marketing and fundraising campaigns with digital stories for their impact on viewers, whereas phase 4 will focus on knowledge dissemination.

RESULTS

Ethics approval for this study was received in March 2021. Data on the feasibility of the study design and the results of the controlled trial will be generated. This study will produce new knowledge on effective ways of promoting mental health awareness and decreasing stigma, with practical importance for future social marketing and fundraising campaigns. The anticipated time for completion within the 2-year study period includes 9 months for phase 1 (knowledge synthesis activities identifying social marketing and fundraising campaigns) and phase 2 (storytelling workshops), 11 months for phase 3 (feasibility assessment and data collection: randomized controlled trial), and 2 months for phase 4 (knowledge dissemination).

CONCLUSIONS

The knowledge generated will have practical implications for the public and for future social marketing and fundraising campaigns promoted by government agencies as well as nonprofit and for-profit organizations by enhancing our understanding of how individuals and societies respond to stories of mental distress and what prompts citizens to help others.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04881084; https://clinicaltrials.gov/ct2/show/NCT04881084.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/33525.

Effects of Renaming Schizophrenia on Destigmatization among Medical Students in One Taiwan University

The stigma associated with serious mental illnesses causes a huge burden on patients, their families, and society. In October 2012, in Taiwan, schizophrenia was renamed to reduce the stigma associated with this disease. The aim of this study was to compare the differences of public stigma, self-stigma, and social distance associated with schizophrenia between old and new name of schizophrenia in medical students. A cross-sectional survey was administered to 180 medical students of Taipei Medical University from October 2014 to February 2015. In total, 123 complete questionnaires were included in this study. Participants completed the modified attribution questionnaire, the perceived psychiatric stigma scale, and modified social distance scale to assess public stigma, self-stigma, and social distance, respectively. We also collected basic demographic data and previous experience of contact with people with mental illness. In total, 52 and 71 of the first- and fourth-year medical students, respectively, participated in the study. Among them, there were 51 females and 72 males. A significant difference in age was observed between the first- and fourth-year groups (20.2 ± 1.7 years vs. 22.7 ± 0.9 years, p < 0.001). After renaming schizophrenia, we noted significant differences in the scores in the modified attribution questionnaire, the perceived psychiatric stigma scale, and the modified social distance scale in all participants and the fourth-year students, respectively. Female gender (Beta = 0.230, p = 0.018) was significantly associated with the difference in the score of the modified attribution questionnaire after name change. The difference in the score of the perceived psychiatric stigma scale after the name change (Beta = 0.277, p = 0.004) and age (Beta = −0.186, p = 0.049) were significantly associated with the difference in the score of the modified social distance scale after name change. In conclusion, renaming was associated with the changes in the scores of the modified attribution questionnaire, the perceived psychiatric stigma scale, and the modified social distance scale toward individuals with schizophrenia in medical students of one Taiwan university. Further studies with large sample sizes, diverse participant backgrounds, and that monitor the subsequent behavioral changes are warranted.

Mental health care and the cultural toolboxes of the present-day Japanese population: Examining suggested patterns of care and their correlates

An extensive body of literature has documented the under-utilization of mental health services among Asian populations, regardless of where they live. Japan is one Asian country where the mental health care system has improved substantially in the recent decades. Yet, Japan continues to report greater under-utilization of mental health services than other developed countries. One primary reason for this is hypothesized to be the cultural climate, which includes the stock of social, cultural and medical knowledge surrounding mental illness. Previous studies have not examined the cultural toolkit (Swidler, 2001) of the Japanese public, nor have they linked these to public attributions or assessments surrounding mental health. The Stigma in Global Context - Mental Health Study (SGC-MHS), a multi-stage probability sample of Japanese residents aged 18-64 years (N = 994) in 2006 provides data to describe the unprompted care suggestions from the general population regarding case scenarios meeting psychiatric criteria for schizophrenia and depression. Guided theoretically by the Network Episode Model, we analyze if and how respondents socially organize solutions into patterns of culturally acceptable care for mental health problems in Japan. Six cultural utilization patterns appear to be shaped by beliefs about underlying attributions, perceived severity of conditions, and type of mental health problem. Further, women, older individuals and those with differing education levels suggest different care patterns than their counterparts. In sum, the findings indicate unique patterns of mental health care recommendations among the Japanese public, which are culturally and socially constrained.

How the use of the term "schizo*" has changed in an Italian newspaper from 2001 to 2015: Findings from a descriptive analysis

The study aims to report the number of newspaper articles including the word "schizo" in the period 2001 - 2015 and to identify possible predictors reinforcing negative stereotypes about people with schizophrenia. The electronic archives of the Italian newspaper "La Stampa" have been searched for the term "schizo". Selected articles were grouped in articles related to mental health (rMH) or article not related to mental health (nrMH). 946 articles were identified. Schizophrenia-related terms were used in 356 (36.03%) article rMH, which mainly reinforce negative stereotypes regarding mental illness both in rMH and nrMH groups. Over time, only in the rMH group a significant reduction of articles reinforcing negative stereotypes was found. Several factors have been identified as predictors of article reinforcing negative stereotypes: unnecessarily dramatic or sensational headline or content; inaccurate or not in the correct context use of medical terminology; emphasis to the illness rather than to the person; mental disorders are the same; disclosure of particular individual has a mental illness. Although there has been a significant reduction in stigmatizing articles, in the rMH group one article out of three reinforces negative stereotypes.

Retreating From Life: The Boy Whose Body Experienced His Pain

The expression of psychological distress through somatic symptoms is most prevalent among children. Somatic symptom disorders represent a difficult category of disorders to treat and they are often misdiagnosed due to their physical symptomology and dismissed due to their malingering stigma. The current case report follows the treatment of David, a 10-year-old Caucasian male, admitted into the pediatric psychiatric ward of a general hospital, uncommunicative, showing little signs of responsiveness, and dependent on nursing staff for basic needs. Following a complex treatment protocol which integrated key elements of psychodynamic and cognitive-behavior (CBT) treatment recommendations for somatic disorders, David was discharged after 6 months as an inpatient. This in-depth case study provides a synthesis of the varied research on somatic symptom disorders and an acute understanding of how to combine the understanding of complex family dynamics and individual personality structure with empirically reinforced treatment strategies.

A randomised controlled trial of repeated filmed social contact on reducing mental illness-related stigma in young adults

AIMS

Public stigma alters attitudes towards people with mental illness, and is a particular concern for young people since most mental health problems occur in adolescence and young adulthood. However, little is known about the long-term effects of repeated filmed social contact (FSC) on reducing mental health-related stigma among young adults in the general population, compared with self-instructional Internet search (INS) and control interventions.

METHODS

This study is a parallel-group randomised controlled trial over 12 months conducted in Tokyo, Japan. A total of 259 university students (male n = 150, mean age = 20.0 years, s.d. = 1.2) were recruited from 20 colleges and universities between November 2013 and July 2014, without being provided information about the mental health-related survey or trial. Participants were assigned to one of three groups before completion of the baseline survey (FSC/INS/control = 89/83/87). The FSC group received a computer-based 30-min social contact film with general mental health education and five follow-up web-based FSCs at 2-month intervals. The INS group undertook a 30-min search for mental health-related information with five follow-up web-based reminders for self-instructional searches at 2-month intervals. The control group played PC games and had no follow-up intervention. The main outcome measures were the future (intended behaviour) domain of the Reported and Intended Behaviour Scale at 12 months after the intervention. Analysis was conducted in September 2015.

RESULTS

At the 12-month follow-up, 218 participants completed the survey (84.1%, 75:70:73). The FSC group showed the greatest change at the 12-month follow-up (FSC: mean change 2.11 [95% CI 1.49, 2.73], INS: 1.04 [0.29, 1.80], control: 0.71 [0.09, 1.33]; FSC v. INS p = 0.037, FSC v. controls p = 0.004). No adverse events were reported during the follow-up period.

CONCLUSIONS

FSC was more successful in reducing stigma at 12 months after intervention than INS or control interventions. FSC could be used to reduce stigma in educational lectures and anti-stigma campaigns targeted at young people.

STUDY REGISTRATION

This study is registered at UMIN-CTR (No. UMIN000012239).

Social distance toward people with schizophrenia is associated with favorable understanding and negative stereotype

Previous studies have suggested the consequence of mental health-related public stigma: the problem of knowledge may develop into problem of attitude and behaviour. However, this has not been directly explored in a longitudinal study. As the secondary analysis from our previous randomized controlled trial (RCT) for 219 participants who completed the survey at the 12-month follow-up, we aimed to investigate whether the knowledge and attitude components of stigma toward people with schizophrenia affect each other. At baseline and at 12 months, three types of stigma scales were measured: favorable understanding, negative stereotype, and social distance toward people with schizophrenia. A structured equation model was fitted to the trajectory of stigma scales taking into account the effect of the other stigma components and the interventions. The results showed that greater social distance toward people with schizophrenia at baseline was associated with less favorable understanding and more negative stereotype at the 12-month follow-up. This was not in line with the existing consequences from the previous studies; however, in line with the recent RCTs showing that social contact is the most effective intervention to reduce stigma. Future observational studies with a larger sample size are needed to clarify this relationship further.

Words matter: after more than a century ‘schizophrenia’ needs rebranding

Professionals, patients and patient organisations have advocated for the renaming of ‘schizophrenia’, seeing the term as misleading, stigmatising and a barrier to specialised care. In countries where a name change has occurred (e.g. Japan), the advantages of renaming seem to far outweigh disadvantages. Nevertheless, a name change would be a long and complex process that would not be useful if it were not accompanied by parallel changes in legislation, services and the education of professionals and the public.

DECLARATION OF INTEREST

None.

Associations between renaming schizophrenia and stigma-related outcomes: A systematic review

Renaming schizophrenia is a potential strategy to reduce the stigma attached to people with schizophrenia. However, the overall associations between renaming schizophrenia and stigma-related outcomes have not been fully elucidated. We conducted a systematic review of studies that empirically examined the outcomes between new or alternative terms and old or existing terms for schizophrenia. We searched for relevant articles in eight bibliographic databases, conducted a Google search, examined reference lists, and contacted relevant experts. We found a total of 2601 reference records, and 23 articles were included in this review. Overall, in countries where schizophrenia has been renamed, the name changes may be associated with improvements in adults' attitudes toward people with schizophrenia, and with increased diagnosis announcement. However, studies conducted in countries where schizophrenia has not been renamed report inconsistent findings. In addition, renaming may not influence portrayals of schizophrenia in the media. Most studies included in our review had a risk of bias in their methodology, and we employed a vote-counting method to synthesize study results; therefore, the impacts of renaming are still inconclusive. Future studies are needed to address the following issues: use of univariate descriptive statistics, adjustment for confounding variables, use of reliable measures, and employing a question that addresses the image of split or multiple personalities. Evidence is limited regarding the associations between renaming and stigma experienced by both people with schizophrenia and their families (e.g., perceived stigma, self-stigma, discrimination experience, and burden). Further research in these populations is needed to confirm the effects of renaming schizophrenia.