Psychiatric Healthcare Experiences of South Asian Patients with Severe Mental Illness Diagnoses and Their Families in New York City: A Qualitative Study

South Asians (SAs) underutilize mental health services compared to many racial and ethnic groups in the United States (US), yet there is limited research on the experiences of SAs living with severe mental illness (SMI). This study examined psychiatric healthcare experiences of SA patients with SMI diagnoses (e.g., severe depression, bipolar disorder, schizophrenia) in New York City. Data collection included semi-structured interviews with 36 participants (21 patients, 11 family members, 4 clinicians). Data was managed in NVivo. Two pairs of SA researchers conducted thematic analysis. Limited mental health knowledge led to delayed care for SAs due to a low perceived need for help. Ease of access, linguistic resources, patient-provider relationships, and family involvement influenced psychiatric healthcare experiences. Prescribed medications, self-motivation, communication, and religious practices were factors aiding symptom management and recovery. Findings highlight the need for improving psychiatric healthcare access and culturally-salient mental health education for SA communities.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Mental health, study skills, social support, and barriers to seeking psychological help among university students: a call for mental health support in higher education

Introduction

Poor mental health among youths is a complex worldwide issue. Many countries with medium-to-low levels of development, particularly those in Southern Europe, have not introduced appropriate mental health and educational strategies to identify the key factors influencing wellbeing, promote psychological wellbeing, and prevent poor mental health among youths. In response to these trends, we sought to uncover insights for developing interventions for youth mental wellbeing. We assessed mental health, study skills, barriers to seeking psychological help, and perceived social support among Kosovar university students, and investigated their experiences with professional mental health services and their needs and perceptions regarding the importance of professional mental health services on campus.

Methods

The study used a parallel mixed-methods design. Participants included 234 university students. Quantitative data were gathered through validated questionnaires, including the Depression, Anxiety, and Stress Scale, Multidimensional Scale of Perceived Social Support, Academic Anxiety Scale, Study Skills Assessment Questionnaire, and the Barriers to Seeking Psychological Help Scale. Qualitative data on the students' experiences with mental health services and their perceptions regarding the importance of professional university mental health services were explored through open-ended questions.

Results

Most students experienced anxiety and depression, more than half were stressed, and most reported poor or moderate study skills. Lack of trust in mental health professionals was a major barrier to seeking psychological help, followed by difficulties in self-disclosure. Perceived social support and academic anxiety were significant predictors of barriers to seeking psychological help. The participants believed that mental health and academic support from the university would help improve their mental wellbeing, study skills, self-esteem, self-perception, and attitudes toward social support; raise awareness regarding mental health; and help them overcome personal and academic challenges.

Discussion

Our findings highlight the need for more comprehensive and accessible mental health services on campuses. By providing adequate support and resources to address various personal and academic factors that contribute to mental health issues in university students, universities can enhance students' academic success and personal growth.

Mental disorder and subsequent marital separation among migrant and non-migrant women

Using national register data between 2006-2014, we investigated the relationship between outpatient mental health service use (a proxy for mental disorder) and subsequent marital separation among women in Norway and whether the strength of the association differed for migrant and non-migrant women. Our sample population included 679,928 married women aged 18-60 years. Service use was strongly associated with marital separation among all women. The relationship was stronger for Filipinas but weaker for Somalis and Russians, compared with non-migrant women. Migration-related factors may influence marital separation among migrant women and barriers to care are likely to exist.

The role of culture on the phenomenology of hallucinations and delusions, explanatory models, and help-seeking attitudes: A narrative review

AIM

Culture has been posited to be involved in the formation and maintenance of delusions and hallucinations. The extent of these differences and how they affect explanatory models of psychosis and help-seeking attitudes remains to be understood. This review aims to present a cultural formulation to account for psychosis onset, symptom maintenance, and help-seeking attitudes.

METHODS

A narrative review was conducted to summarize the existing evidence base regarding cross-cultural differences in hallucinatory and delusional prevalence, explanatory models, and help-seeking attitudes in First Episode Psychosis (FEP) and Non-FEP Schizophrenia samples.

RESULTS

Sixteen studies were eligible for inclusion. In terms of positive symptom specificity, cross-cultural differences were found. Specifically, auditory and visual hallucinations occurred most frequently in African patients, persecutory and grandiose delusions occurred at higher rates in African, Pakistani, and Latino patients, while delusions of reference were most prevalent in White-British groups. Three explanatory models were identified. Westerners tended to endorse a bio-psychosocial explanation, which was associated with increased help-seeking, engagement, and positive medication attitudes. Asian, Latino, Polish, and Māori patients endorsed religious-spiritual explanatory models, while African patients opted for a bewitchment model. The religious-spiritual and bewitchment models were associated with a longer duration of untreated psychosis (DUP) and poorer engagement with mental health services.

CONCLUSIONS

These findings highlight the important influence of culture in the formation and maintenance of positive symptoms of psychosis, engagement, and help-seeking attitudes across different ethnic groups. The incorporation of cultural beliefs in formulation development could facilitate enriched CBTp practices and improved engagement amongst different cultural groups with Early Intervention Services.

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

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

ABSTRACT

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

AIM/QUESTION

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

METHOD

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

RESULTS

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

DISCUSSION AND IMPLICATIONS FOR PRACTICE

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

International rates of receipt of psychological therapy for psychosis and schizophrenia: systematic review and meta-analysis

BACKGROUND

International clinical practice guidelines commonly recommend the provision of psychological therapies for psychosis and schizophrenia as an adjunct to medication. However, access to recommended therapies in routine clinical practice is limited. The aim of this review was to synthesise the available data on the provision of recommended psychological therapies for psychosis and schizophrenia across international mental health systems.

METHODS

Electronic databases (PsychINFO, Pubmed and EMBASE) were searched for audits, service evaluation projects, or surveys, which reported data on rates of offer or receipt of any recommended psychological therapy or therapeutic intervention as part of routine clinical care.

RESULTS

Twenty-two eligible studies from 9 countries were identified (N participants = 79,407). The most commonly recommended therapies in national guidelines were Cognitive-Behavioural Therapy for Psychosis (CBTp) and Family Interventions (FI). The overall pooled prevalence of rate of receipt of CBTp was 24% [95% CI 0.15-0.32] based on 15 studies (N = 42,494), with a higher rate of receipt of therapy found when pooling data from Early Intervention services only (41% [95% CI 0.21-0.60], 6 studies, N = 11,068). The overall pooled prevalence of rate of receipt of FI was 30% [95% CI 0.22-0.37] based on 14 studies (N = 13,863).

CONCLUSIONS

Overall rates of receipt of recommended psychological therapies for psychosis were low across the 9 countries data were available for in this review. However, there were high rates of heterogeneity across studies, meaning that pooled estimates should be interpreted with caution. Sources of heterogeneity included different service settings (e.g. early intervention vs. non-early intervention services), and varying methods used to collect the data (e.g. audit of electronic health records vs. self-report etc.). There were no available data from the continents of South America, Asia, or Africa, meaning that a truly global picture of provision of psychological therapies for psychosis and schizophrenia is currently lacking.

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.

Positive psychotic symptoms in childhood and adolescence

Based on the assumption of a universal neurodevelopmental model of psychosis, especially of the schizophrenia spectrum, the diagnosis (and treatment) of psychosis in minors commonly follows those in adults. Yet, as our review demonstrates, recent years have seen an emergence of studies of minors indicating that developmental aspects may play a crucial role in the prevalence and appraisal of diagnostically relevant positive psychotic symptoms in their full-blown and subthreshold forms, including neurobiogenetic and other risk factors, such as migration. Thus, caution is advised to not overpathologize potentially transient and clinically irrelevant occurrence of (subthreshold) positive psychotic symptoms in the diagnosis and treatment of psychotic disorders and their clinical high-risk states in minors. More studies on developmental aspects are urgently needed.

The Relationship between the Therapeutic Alliance and Suicidal Experiences in People with Psychosis Receiving Therapy

Few studies have examined the relationship between the therapeutic alliance in therapy and suicidal experiences. No studies have examined this relationship with people with non-affective psychosis. The present study sought to redress this gap in the literature. Sixty-four participants with non-affective psychosis and suicidal experiences who were receiving a suicide-focused cognitive therapy were recruited. Self-reported suicidal ideation, suicide plans, suicide attempts, depression, and hopelessness were collected from participants prior to starting therapy. Suicidal experience measures were collected again post-therapy at 6 months. Therapeutic alliance ratings were completed by clients and therapists at session 4 of therapy. Dose of therapy was documented in number of minutes of therapy. Data were analyzed using correlation coefficients, independent samples t-tests, a multiple hierarchical regression, and a moderated linear regression. There was no significant relationship found between suicidal ideation prior to therapy and the therapeutic alliance at session 4, rated by both client and therapist. However, there was a significant negative relationship between the client-rated therapeutic alliance at session 4 and suicidal ideation at 6 months, after controlling for pre-therapy suicidal ideation, depression, and hopelessness. Furthermore, the negative relationship between the client-rated alliance and suicidal ideation was the strongest when number of minutes of therapy was 15 h or below. A stronger therapeutic alliance developed in the first few sessions of therapy is important in ameliorating suicidal thoughts in people with psychosis. Nevertheless, it is not necessarily the case that more hours in therapy equates to a cumulative decrease in suicidal ideation of which therapists could be mindful. A limitation of the current study was that the alliance was analyzed only at session 4 of therapy, which future studies could seek to redress.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Individual-level socioeconomic status and contact or familiarity with people with mental illness: a cross-sectional study in Wuhou District, Chengdu, Southwest China

Background

People with mental illness (PWMI) often suffer from public stigma, which can make them unwilling to seek help and reduce access to early treatment. The aims of this study were to determine attitudes towards PWMI among the general public in a Chinese sample and to explore the relationships with sociodemographic characteristics.

Methods

A community-based, cross-sectional study was conducted from March to June 2019. The participants’ attitudes towards PWMI were evaluated by the Chinese version of the Social Distance Scale (SDSC). An independent-sample T-test and one-way ANOVA were used to determine the association of categorical variables with the outcome variable. Multiple linear regression and Spearman correlations were computed to explore the correlation between SDSC scores and individual-level socioeconomic status (SES).

Results

A total of 1437 participants were recruited, and their total SDSC score was 12.53 (SD: 3.11). Univariate analysis results showed that age, education level, educational attainment, and individual-level SES as well as whether they were caregivers/family members of PWMI were correlated with SDSC scores. The results of regression analysis showed a significant effect caused by contact or familiarity with PWMI (B = -1.134, β = -.190, P < 0.001), as well as for individual-level SES (B = -.339, β = -.110, P < 0.001). Spearman correlation results showed that SDSC scores were negatively correlated with individual-level SES (r = -.078, p < 0.01) and contact or familiarity with PWMI (r = -.168, p < 0.001).

Conclusion

This study reveals that public stigma towards PWMI is common in Southwest China. Individuals who are not a family member or a caregiver of PWMI or have low education level or low individual-level SES need to be provided more anti-stigma interventions. Contacting with PWMI is also a potentially beneficial measure to reduce social distance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01422-y.

Deconstructing stigma as a barrier to treating DGBI: Lessons for clinicians

Stigma, defined as social devaluation based on negative stereotypes toward a particular population, is prevalent within health care and is a common phenomenon in disorders of gut-brain interaction (DGBI). Characteristically, DGBI including functional dyspepsia (FD) lack a structural etiology to explain symptoms, have high psychiatric co-morbidity, and respond to neuromodulators traditionally used to treat psychopathology. As a result, these disorders are frequently and wrongly presumed to be psychiatric and carry a great deal of stigma. Stigma has profound adverse consequences for patients, including emotional distress, medication non-adherence, barriers to accessing care, and increased symptoms. The basis for stigma dates back to the 17th Century concept of mind-body dualism. Patients and health care providers need to understand the factors that promote stigma and methods to ameliorate it. In this minireview, we address the data presented in Yan et al.'s (Neurogastroenterol Motil, 2020, e13956). We offer concrete solutions for clinicians to mitigate the impact of stigma to optimize treatment adherence and clinical outcomes for patients with DGBI.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Engaging South Asian youth and families: A clinical review

OBJECTIVE

South Asians (SAs), a rapidly growing minority group in the United States are underrepresented in mental health research. They represent a unique sub-group of Asian immigrants in that their journey to the United States in the last 50 years was driven by the pursuit of academic and career opportunities. Our goal is to provide a topical overview of factors contributing to the mental health challenges of South Asian American (SAA) youth and to describe culturally sensitive approaches that would provide effective treatment for SAA youth and their families.

METHODS

We conducted a review of published literature in PubMed and PsycInfo search engines using the key words South Asian immigrants, South Asian Americans, psychological, psychiatric, mental health treatment, therapy and interventions.

RESULTS

The challenges faced by these highly educated families are distinctive in that there is a struggle to maintain ethnic identity based on collectivism while embracing American ideals of individualism. These opposing values along with model minority expectations put SAs at high risk for mental health concerns and acculturative family distancing. Furthermore, mental health stigma impedes help-seeking. Mental health practitioners must navigate the different value systems of the parent-child dyad without ostracizing either generation and deliver effective care. Hence, culturally adapted family therapy and community-based approaches may be particularly relevant in SA youth.

CONCLUSION

Our article outlines common family attitudes and issues pertinent to mental health in youth and discusses useful clinical approaches to dealing with SAA youth and their families.

Countries and Cultural Differences in the Stigma of Mental Illness: The East–West Divide

Mental illness is a global public health crisis. Although rates of untreated cases stand as a primary problem, stigma is a significant obstacle. Yet, global differences in levels and roots of stigma remain poorly understood. Using the Stigma in Global Context–Mental Health Study (SGC-MHS) data, we analyzed data on two components of stigma—prejudice and discriminatory potential—attached to clinically diagnostic cases of depression and schizophrenia. We examined whether stigma was higher in the East than West. Furthermore, we hypothesized that the link between prejudice and discriminatory potential in the East was due, in part, to cultural differences in the attributions about mental illness. With SGC-MHS’ nationally representative vignette data from over 11,000 respondents in 11 relevant countries (four Eastern, seven Western), analyses replicated past research of higher levels of stigma and more moral attributions in Eastern countries, particularly for depression. Moreover, prejudice-related disclosure spillover concerns predicted discriminatory potential (social distance) in the East, but not the West; this was driven by a greater emphasis on moral attributions in the East. Finally, exploratory analyses found that Western respondents endorsed higher discrimination for minority (vs. majority) group members with mental illness. In Eastern countries, the same pattern emerged for schizophrenia, but the reverse occurred for depression—greater stigma for majority as compared with minority group members. Together, these findings suggest that cultural differences in the sources of prejudice and attributions about the etiology of mental illness contribute, at least in part, to global differences in the profile of stigma.