Mental health related stigma as a ‘wicked problem’: the need to address stigma and consider the consequences

Recent reviews on the evidence base for mental health related stigma reduction show that under certain conditions interpersonal contact is effective in promoting more positive attitudes, reduced desire for social distance, and increased stigma related knowledge (knowledge which disconfirms beliefs based on stereotypes). Short-term interventions may have effects that are attenuated over time; longer term programmes may support sustained improvements, but research following up long-term interventions is scarce. However, the effectiveness of these interventions should not obscure the nature of stigma as a social problem. In this article we describe stigma as a ‘wicked problem’ to highlight some implications for intervening against stigma and evaluating these efforts. These include the risks of unintended consequences and the need to continually reformulate the concept of stigma, to ensure that tackling stigma at the structural, interpersonal, and intrapersonal levels become part of the core business of stakeholder organisations. We compare the main targets of anti-stigma programmes with what is known about the sources of stigma and discrimination and their impacts to identify targets for future intervention. In some cases, interventions have been directed at the interpersonal level when structural level intervention is also needed; in others, systematic reviews have not so far identified any interventions

Stigma related to targeted school-based mental health interventions:A systematic review of qualitative evidence

BackgroundSchool-based mental health services have been advocated to increase access to psychological support for children and adolescents. However, concerns have been raised about the potential stigma associated with selection of students and the visibility of school-based service contact.MethodsThis review assessed findings from qualitative studies to identify potential stigmatising effects of participation in targeted school-based mental health interventions for students attending primary- or secondary-level education. Eight articles (reflecting seven studies) were identified through electronic database searches (PsycInfo, EMBASE, Medline, CINAHL, ERIC), supplemented by citation and reference searches and expert consultations. Data were synthesised according to established guidelines for thematic synthesis.ResultsThree overarching themes were identified: “anticipated and experienced stigma”, “consequences of stigma” and “mitigating strategies”. These findings illustrate how pervasively stigma can compromise efforts to increase access to mental health care through targeted school-based provision, but also outline strategies endorsed by students for alleviating the risk and/or impact of stigma.LimitationsThese findings need to be considered in view of the relative scarcity of surveyed evidence. Furthermore, as all evidence came from high-income and Western countries, the applicability to other contexts is unclear.ConclusionsThis synthesis reflects the first overview of qualitative evidence regarding stigmatising experiences and concerns associated with students’ engagement with targeted school-based mental health interventions. The findings can inform efforts to mitigate stigma-related barriers to students’ engagement in targeted mental health support, and serve to guide future research in this area

Socioeconomic inequalities in duration of untreated psychosis : evidence from administrative data in England

Background. Duration of untreated psychosis (DUP) is an important measure of access to care as it predicts prognosis and treatment outcomes. Little is known about potential socioeconomic inequalities in DUP. The aim of this study was to investigate inequalities in DUP associated with socioeconomic deprivation in a national cohort in England. Method. We analysed a cohort of 887 patients with a first-episode in psychosis using the administrative Mental Health Services Dataset in England. We used a Generalised Linear Model to account for non-linearity in DUP and looked at inequalities across the whole distribution of DUP using quantile regression. Results. The median DUP was 22 days (mean = 74 days) with considerable variations between and within the 31 hospital providers. We found evidence of significant inequalities regarding the level of socioeconomic deprivation. Patients living in the second, third, and fourth deprived neighbourhood quintiles faced a 36, 24, and 31 day longer DUP than patients from the least deprived neighbourhoods. Inequalities were more prevalent in higher quantiles of the DUP distribution. Unemployment prolonged DUP by 40 days. Having been in contact with mental health care services prior to the psychosis start significantly reduced the DUP by up to 53 days. Conclusions. Socioeconomic deprivation is an important factor in explaining inequalities in DUP. Policies to improve equitable access to care should particularly focus on preventing very long delays in treatment and target unemployed patients as well as people that have not been in contact with any mental health professional in the past

Conditional disclosure on pathways to care: coping preferences of young people at risk of psychosis

The interrelationship between stigma and help-seeking is under-researched among children and adolescents. This study explored stigma in relation to pathways to care among young people putatively in an early stage of increased risk of developing psychotic disorders. “Pathways to care” was defined as help-seeking and support from informal and formal resources, and increased risk was determined through the presence of persistent psychotic-like experiences and internalizing/externalizing psychopathology. Twenty-nine qualitative interviews were analyzed using thematic analysis. We defined the superordinate theme in these data as “conditional disclosure,” a concept reflecting the rules and prerequisites that influenced how/whether participants sought help. Through parallels between these findings and established stigma theory, we examined how these conditions could be interpreted as influenced by stigma. Our findings demonstrate the influence of stigma on young people’s perceptions of a range of pre-clinical symptoms, and on how they seek support for these symptoms

Core components of mental health stigma reduction interventions in low- and middle-income countries: a systematic review

Aims To identify and categorise core components of effective stigma reduction interventions in the field of mental health in low- and middle-income countries (LMICs) and compare these components across cultural contexts and between intervention characteristics. Methods Seven databases were searched with a strategy including four categories of terms ('stigma’, ‘mental health’, ‘intervention’ and ‘low- and middle-income countries’). Additional methods included citation chaining of all papers identified for inclusion, consultation with experts and hand searching reference lists from other related reviews. Studies on interventions in LMICs aiming to reduce stigma related to mental health with a stigma-related outcome measure were included. All relevant intervention characteristics and components were extracted and a quality assessment was undertaken. A ‘best fit’ framework synthesis was used to organise data, followed by a narrative synthesis. Results Fifty-six studies were included in this review, of which four were ineffective and analysed separately. A framework was developed which presents a new categorisation of stigma intervention components based on the included studies. Most interventions utilised multiple methods and of the 52 effective studies educational methods were used most frequently (n = 83), and both social contact (n = 8) and therapeutic methods (n = 3) were used infrequently. Most interventions (n = 42) based their intervention on medical knowledge, but a variety of other themes were addressed. All regions with LMICs were represented, but every region was dominated by studies from one country. Components varied between regions for most categories indicating variation between cultures, but only a minority of studies were developed in the local setting or culturally adapted. Conclusions Our study suggests effective mental health stigma reduction interventions in LMICs have increased in quantity and quality over the past five years, and a wide variety of components have been utilised successfully – from creative methods to emphasis on recovery and strength of people with mental illness. Yet there is minimal mention of social contact, despite existing strong evidence for it. There is also a lack of robust research designs, a high number of short-term interventions and follow-up, nominal use of local expertise and the research is limited to a small number of LMICs. More research is needed to address these issues. Some congruity exists in components between cultures, but generally they vary widely. The review gives an in-depth overview of mental health stigma reduction core components, providing researchers in varied resource-poor settings additional knowledge to help with planning mental health stigma reduction interventions

Impact of mental health stigma on help-seeking in the Caribbean:Systematic review

BackgroundMental health conditions often go untreated, which can lead to long-term poor emotional, social physical health and behavioural outcomes, and in some cases, suicide. Mental health-related stigma is frequently noted as a barrier to help seeking, however no previous systematic review has considered evidence from the Caribbean specifically. This systematic review aimed to address two research questions: (1) What is the impact of mental health stigma on help-seeking in the Caribbean? (2) What factors underlie the relationship between stigma and help-seeking in the Caribbean?MethodsA systematic search was conducted across six electronic databases (Medline, Embase, Global Health, PsychInfo, Scopus and LILACS). The search included articles published up to May 2022. Experts in the field were consulted to provide publication recommendations and references of included studies were checked. Data synthesis comprised of three components: a narrative synthesis of quantitative findings, a thematic analysis of qualitative findings, and a meta-synthesis combining these results.ResultsThe review included nine articles (reflecting eight studies) totaling 1256 participants. A conceptual model was derived from the meta-synthesis, identifying three themes in relation to mental health stigma and help-seeking in the Caribbean: (i) Making sense of mental health conditions'; (ii) Anticipated/Experienced stigma-related experiences and (iii) Individual characteristics.ConclusionThis review provides insights into the relationship between mental health stigma and help-seeking in the Caribbean based upon the current research evidence. This can be applied in the design of culturally appropriate future research, and to support policy and practice towards stigma reduction, and improved mental care help-seeking in the Caribbean

Selected breakpoints of net forest carbon uptake at four eddy-covariance sites

Extensive studies are available that analyse time series of carbon dioxide and water flux measurements of FLUXNET sites over many years and link these results to climate change such as changes in atmospheric carbon dioxide concentration, air temperature and growing season length and other factors. Many of the sites show trends to a larger carbon uptake. Here we analyse time series of net ecosystem exchange, gross primary production, respiration, and evapotranspiration of four forest sites with particularly long measurement periods of about 20 years. The regular trends shown are interrupted by periods with higher or lower increases of carbon uptake. These breakpoints can be of very different origin and include forest decline, increased vegetation period, drought effects, heat waves, and changes in site heterogeneity. The influence of such breakpoints should be included in long-term studies of land-atmosphere exchange processes.Peer reviewe

Heavy metal recovery from the fine fraction of solid waste incineration bottom ash by wet density separation

This work is aimed at exploring the recovery of heavy metals from the fine fraction of solid waste incineration bottom ash. For this study, wet-discharged bottom ash fine-fraction samples from full-scale treatment plants in Germany and Sweden were analyzed. The potential for the recovery of heavy metal compounds was investigated through wet density-separation with a shaking table. The feed materials were processed without any pre-treatment and the optimum processing conditions were determined by means of design of experiments. Tilt angle and stroke frequency were identified as the most relevant parameters, and the optimum settings were − 7.5° and 266 rpm, respectively. The obtained balanced copper enrichments (and yields) were 4.4 (41%), 6.2 (28%) and 2.4 (23%). A maximum copper enrichment of 14.5 with 2% yield was achieved, providing a concentrate containing 35.9 wt.% relevant heavy metal elements. This included 26.3 wt.% iron, 4.3 wt.% zinc and 3.8 wt.% copper. In conclusion, density separation with shaking tables can recover heavy metals from bottom ash fine fractions. Medium levels of heavy metal enrichment (e.g., for Cu 2.7–4.4) and yield (Cu: 26–41%) can be reached simultaneously. However, the separation performance also depends on the individual bottom ash sample