Enhancing mental health awareness in emergency services (the ENHANcE I project): cross-sectional survey on mental health stigma among emergency services staff

A Systematic Review and Meta-Analysis of Implicit Stigma Toward People with Mental Illness Among Different Groups: Measurement, Extent, and Correlates

Introduction

Implicit association tests have been extensively applied to reveal socially unacceptable and concealed stigma. Studies have explored the implicit stigma toward mental illness in specific groups, with limited comparisons across different groups. To investigate the implicit stigma toward mental illness among different groups, along with the interaction between implicit and explicit measurements.

Methods

Based on PRISMA guidelines, Web of Science, Embase, PubMed/MEDLINE, Cochrane Library, and PsycINFO were searched from 1998 to April 18, 2024. Searches were updated through February 12, 2025. The Medical Education Research Quality Instrument (MERSQI) served as the quality evaluation framework, and Stata 12.0 facilitated the conduct of a meta-analysis.

Results

The analysis included fifty studies in the systematic review and thirty in the meta-analysis. Most studies used "mental illness" or related physical illness terms as concept words, paired with emotionally contrasting attribute words. Twenty-eight studies calculated the implicit effect using an improved algorithm, while thirty-eight examined the correlations between implicit and explicit measures. The pooled standardized mean differences (SMDs) revealed that the lowest D scores were observed in the general population (SMD = 0.79, P < 0.001), followed by healthcare providers (SMD = 1.09, P = 0.054), students (SMD = 1.17, P < 0.001) and people with mental illness (SMD = 1.20, P < 0.001).

Conclusion

The findings indicated that the selection of concept and attribute words, as well as the processing of data measuring implicit stigma, was not standardized. No reliable correlation was found between implicit and explicit measures. Despite the heterogeneity of included studies, the general public demonstrated the most positive attitudes, while individuals with mental illness exhibited negative attitudes. Further research is required to develop personalized anti-stigma interventions for different groups and regions based on these results, particularly from the perspective of implicit stigma.

Interventions Targeting Resistance and Resilience Among Emergency Medical Service Clinicians: A Systematic Review

OBJECTIVES

To systematically review the effectiveness and harms of interventions to promote resistance and resilience regarding mental health and occupational stress issues among emergency medical service (EMS) clinicians.

METHODS

We registered the systematic review prospectively on PROSPERO (CRD42023465325). We searched Medline, Embase, CENTRAL, CINAHL, ClinicalTrials.gov, journals, and websites for studies published from January 1, 2001, through June 30, 2024. We conducted duplicate screening of titles and abstracts followed by full texts of potentially relevant abstracts. We included studies of EMS clinicians in high-income countries that evaluated interventions targeting resistance or resilience regarding mental health or occupational stress issues. We assessed the risk of bias and evaluated strength of evidence (SoE) using standard methods.

RESULTS

We included seven studies (one randomized controlled trial, one controlled trial with a waitlist control, four pre-post studies, and one prospective cohort [single group] study) that evaluated a total of 425 EMS clinicians. We deemed five of the seven studies to have high risk of bias, one moderate risk, and one low risk. No meta-analysis was feasible because of heterogeneity in the interventions evaluated across studies. Mindfulness-building interventions targeting resistance and resilience among EMS clinicians were associated with reduced burnout at up to 6 months of follow-up (low SoE). The evidence was insufficient regarding the impacts of interventions targeting both resistance and resilience on anxiety and depression. No conclusions are possible for resistance-only or resilience-only interventions. No studies reported on the effectiveness of any interventions in reducing hospitalizations, post-traumatic stress disorder, substance use, suicidality, or withdrawals from the workforce. No studies reported on unintended harms of interventions.

CONCLUSIONS

Given the sparse evidence identified in this systematic review, evidence-based options to improve mental health outcomes for EMS clinicians are very limited. Future research is urgently needed to inform strategies to address the many mental health and occupational stress issues that face the EMS clinician workforce.

Attitudes of ambulance service staff towards people with mental illness: A cross-sectional survey in the Verona province, Italy

Healthcare professionals can be sources of stigma for people with mental illness. Ambulance personnel are often the first healthcare providers that people with mental illness encounter during physical and mental health crises and their attitudes may be influenced by misconceptions and stereotyping views. This study aimed to assess the attitudes of ambulance personnel toward people with mental illness using the Opening Minds Stigma Scale for Health Care Providers (OMS-HC) and to evaluate its psychometric properties. The study involved 510 ambulance staff members from a non-profit organization. The original factor structure of the OMS-HC, comprising three subscales was confirmed. The internal consistency for the OMS-HC total score was good (α=0.75) and acceptable for the subscales (Social Distance α=0.66; Attitudes α=0.59; Disclosure/Help-Seeking α=0.61). One-third of respondents displayed stigmatizing attitudes on half of the OMS-HC items. Higher scores were associated with being male, having lower levels of education, and working as both rescuers and ambulance drivers and with feeling uncomfortable when dealing with patients with mental illness. Overall, stigmatizing attitudes towards individuals with mental illness are prevalent among ambulance staff. The Italian version of the OMS-HC for ambulance personnel demonstrated satisfactory psychometric properties and is recommended for evaluating training programs targeting this population.

Pilot evaluation of a brief training video aimed at reducing mental health stigma amongst emergency first responders (the ENHANcE II study)

BACKGROUND

First responders (i.e. police and ambulance staff) have increasingly become part of the mental health care system, often being the first port of call for those experiencing a crisis. Despite their frequent involvement in supporting those with mental health problems, there is evidence that mental health stigma is high amongst first responders.

AIMS

The aim of the present study was to evaluate a brief training video aimed at reducing mental health stigma amongst first responders.

METHODS

First responders watched a training video based on the cognitive behavioural model of mental health stigma, and involved contributions from people with lived experience, and first responders. Measures of mental health stigma were collected before and after viewing the training.

RESULTS

The training video produced small but significant improvements in mental health stigma, and these effects did not differ between police and ambulance staff. We were unable to determine what psychological constructs mediated this change in stigma. The feedback on the training video was generally positive, but also indicated some key areas for future development.

CONCLUSIONS

The present study provides encouraging evidence that levels of mental health stigma can be improved using a resource-light training intervention.

Investigating the Relationship Between Psychosocial Safety Climate and Mental Illness Stigma Among Emergency Medical Service Clinicians

OBJECTIVES

To examine the relationship between psychosocial safety climate (PSC) and mental illness stigma among emergency medical service (EMS) clinicians. Despite the presence of mental health services at many EMS agencies, workers often do not seek treatment due to mental illness stigma. To facilitate treatment receipt and maintain a healthy workforce, we must understand factors contributing to stigma. Psychosocial safety climate refers to the degree to which workers perceive that their organization fosters a work environment focused on the protection of psychological health and safety. Despite its relevance, the relationship between PSC and mental illness stigma has yet to be examined.

METHODS

Participants were recruited from EMS agencies in the Northeastern U.S. Census Region. We used an observational research design and multiple linear regression to investigate the relationship between overall levels of PSC using the Psychosocial Climate Scale (PSC-12) and mental illness stigma using the Endorsed and Anticipated Stigma Inventory - Workplace Stigma Subscale. We also examined separate facets of PSC to determine if one was more related to stigma. Using established guidelines and the Wilcoxon rank-sum test, we compared workers rating their agencies as having high-risk (≤37 points) or low-risk PSC levels (≥41 points).

RESULTS

The sample was n = 124 EMS clinicians (Mage = 29.6, SDage = 9.2, 53.2% male). Most were White (88.7%) with some college/college degree (79.8%). After adjusting for age, gender, race, education, and mental health treatment receipt, clinicians reporting that their workplaces were less focused on psychosocial safety and health (i.e., lower overall levels of PSC) also reported elevated levels of stigma (b = -0.27, SE = 0.05, 95% CI = -0.37, -0.17, p < .001). Exploratory analyses indicated that no PSC facet was more related to stigma than another. Clinicians reporting high-risk levels displayed stigma levels that were 38% higher compared to clinicians reporting low-risk PSC levels.

CONCLUSIONS

Psychosocial safety climate is an important and modifiable intervention target linked to mental illness stigma in EMS clinicians. Organizational policies, practices, and procedures that convey that mental health is valued and should be protected may reduce stigma and facilitate treatment receipt among this high-risk population.

Suicide among emergency service workers: a retrospective mortality study of national coronial data, 2001-2017

BACKGROUND

Emergency service workers (ESW) are known to be at increased risk of mental disorders but population-level and longitudinal data regarding their risk of suicide are lacking.

METHOD

Suicide data for 2001-2017 were extracted from the Australian National Coronial Information Service (NCIS) for two occupational groups: ESW (ambulance personnel, fire-fighters and emergency workers, police officers) and individuals employed in all other occupations. Age-standardised suicide rates were calculated and risk of suicide compared using negative binomial regression modelling.

RESULTS

13 800 suicide cases were identified among employed adults (20-69 years) over the study period. The age-standardised suicide rate across all ESW was 14.3 per 100 000 (95% CI 11.0-17.7) compared to 9.8 per 100 000 (95% CI 9.6-9.9) for other occupations. Significant occupational differences in the method of suicide were identified (p < 0.001). There was no evidence for increased risk of suicide among ESW compared to other occupations once age, gender and year of death were accounted for (RR = 0.99, 95% CI 0.84-1.17; p = 0.95). In contrast, there was a trend for ambulance personnel to be at elevated risk of suicide (RR = 1.41, 95% CI 1.00-2.00, p = 0.053).

CONCLUSION

Whilst age-standardised suicide rates among ESW are higher than other occupations, emergency service work was not independently associated with an increased risk of suicide, with the exception of an observed trend in ambulance personnel. Despite an increased focus on ESW mental health and wellbeing over the last two decades, there was no evidence that rates of suicide among ESW are changing over time.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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