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

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

Strategy modulates spatial perspective-taking: evidence for dissociable disembodied and embodied routes

Previous research provides evidence for a dissociable embodied route to spatial perspective-taking that is under strategic control. The present experiment investigated further the influence of strategy on spatial perspective-taking by assessing whether participants may also elect to employ a separable “disembodied” route loading on inhibitory control mechanisms. Participants(N=92)undertook both the “own body transformation”(OBT)perspective-taking task,requiring speeded spatial judgments made from the perspective of an observed figure,and a control task measuring ability to inhibit spatially compatible responses in the absence of a figure.Perspective-taking performance was found to be related to performance on the response inhibition control task,in that participants who tended to take longer to adopt a new perspective also tended to show a greater elevation in response times when inhibiting spatially compatible responses.This relationship was restricted to those participants reporting thatthey adopted the perspective of another by reversing left andright whenever confronted with a front-view figure;it was absent in those participants who reported perspective-taking by mentally transforming their spatial orientation to align with that of the figure.Combined with previously published results,these findings complete a double dissociation between embodied and disembodied routes to spatial perspective-taking,implying that spatial perspective-taking is subject to modulation by strategy,and suggesting that embodied routes to perspective-taking may place minimal demands on domain general executive functions

Development of mental health indicators at the district level in Madhya Pradesh, India: mixed methods study

Background: Strengthening routine information systems for mental health can augment scale up of community mental health services in India and other low- and middle-income countries. Currently little routine data is available in Indian settings. This study aimed to develop a core set of indicators for monitoring mental health care in primary health care settings Methods: By using a sequential exploratory mixed methods design, key mental health indicators measuring service delivery and system performance were developed for the context of Madhya Pradesh, India. The research design involved a situation analysis, and conducting a prioritisation exercise and consultation workshops with key stakeholders. Results: This study resulted in nine key mental health indicators covering both mental health service delivery indicators and mental health system indicators for Sehore district of Madhya Pradesh. Mean indicator priority scores ranging from 4.48 to 3.78 were reported. Conclusions: This study demonstrated a phased approach to strengthen routine information systems for mental health at a primary care level in India. We recommend that similar research methods can be applied across comparable settings and these indicators can be adopted as a part of national routine information systems

Recovery from severe mental health problems: a systematic review of service user and informal caregiver perspectives

Introduction: The recovery approach aims to have users' perspectives at the heart of service development and research; it is a holistic perspective that considers social needs, personal growth and inclusion. In the last decade recovery-oriented research and practice has increased greatly, however, a comprehensive model of recovery considering exclusively the perspectives of people with lived experience has not been devised. Aims: This review aimed to develop a framework and contextualize service users' and informal caregivers' understanding of recovery from severe mental health problems. Methods: We systematically searched 6 databases including key terms related to knowledge, experience and narratives AND mental health AND personal recovery. The search was supplemented with reference sourcing through gray literature, reference tracking and expert consultation. Data analysis consisted of a qualitative meta-synthesis using constant comparative methods. Results: Sixty-two studies were analyzed. A pattern emerged regarding the recovery paradigms that the studies used to frame their findings. The resulting recovery framework included the domains Social recovery; Prosperity (Legal, political, and economic recovery); Individual Recovery; and Clinical Recovery Experience (SPICE). Service users' definitions of recovery tended to prioritize social aspects, particularly being accepted and connecting with others, while caregivers focused instead on clinical definitions of recovery such as symptom remission. Both groups emphasized individual aspects such as becoming self-sufficient and achieving personal goals, which was strongly linked with having economic means for independence. Conclusions: The recovery model provided by this review offers a template for further research in the field and a guide for policy and practice. Predominant definitions of recovery currently reflect understandings of mental health which focus on an individual perspective, while this review found an important emphasis on socio-political aspects. At the same time, only a small number of studies took place in low-income countries, focused on minoritized populations, or included caregivers' perspectives. These are important gaps in the literature that require further attention. Systematic Review Registration: The review protocol was registered on PROSPERO (CRD42017076450); https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=76450

Mental health stigma and discrimination in Ethiopia:evidence synthesis to inform stigma reduction interventions

BACKGROUND: People with mental illnesses are at an increased risk of experiencing human rights violations, stigma and discrimination. Even though mental health stigma and discrimination are universal, there appears to be a higher burden in low- and middle-income countries. Anti-stigma interventions need to be grounded in local evidence. The aim of this paper was to synthesize evidence on mental health stigma and discrimination in Ethiopia to inform the development of anti-stigma interventions.METHODS: This evidence synthesis was conducted as a part of formative work for the International Study of Discrimination and Stigma Outcomes (INDIGO) Partnership research program. Electronic searches were conducted using PubMed for scientific articles, and Google Search and Google Scholar were used for grey literature. Records fulfilling eligibility criteria were selected for the evidence synthesis. The findings were synthesized using a framework designed to capture features of mental health stigma to inform cultural adaptation of anti-stigma interventions.RESULTS: A total of 37 records (2 grey literature and 35 scientific articles) were included in the evidence synthesis. Some of these records were described more than once depending on themes of the synthesis. The records were synthesized under the themes of explanatory models of stigma (3 records on labels and 4 records on symptoms and causes), perceived and experienced forms of stigma (7 records on public stigma, 6 records on structural stigma, 2 records on courtesy stigma and 4 records on self-stigma), impact of stigma on help-seeking (6 records) and interventions to reduce stigma (12 records). Only two intervention studies assessed stigma reduction- one study showed reduced discrimination due to improved access to effective mental health care, whereas the other study did not find evidence on reduction of discrimination following a community-based rehabilitation intervention in combination with facility-based care.CONCLUSION: There is widespread stigma and discrimination in Ethiopia which has contributed to under-utilization of available mental health services in the country. This should be addressed with contextually designed and effective stigma reduction interventions that engage stakeholders (service users, service providers, community representatives and service developers and policy makers) so that the United Nations universal health coverage goal for mental health can be achieved in Ethiopia

Gaps and challenges: WHO treatment recommendations for tobacco cessation and management of substance use disorders in people with severe mental illness

Background: People with severe mental disorders (SMD) experience premature mortality mostly from preventable physical causes. The World Health Organization (WHO) have recently produced guidelines on the management of physical health conditions in SMD. This paper presents the evidence which led to the recommendations for tobacco cessation and management of substance use disorders in SMD. Methods: Scoping reviews informed two PICO (Population Intervention, Comparator, Outcome) questions relating to tobacco cessation and management of substance use disorders in SMD. Systematic searches led to the identification of systematic reviews with relevant evidence to address these questions. Retrieved evidence was assessed using GRADE methodology, informing the development of guidelines. Results: 1434 records were identified through systematic searches for SMD and tobacco cessation, of which 4 reviews were included in GRADE tables and 18 reviews in narrative synthesis. For SMD and substance use disorders, 4268 records were identified, of which 4 studies from reviews were included in GRADE tables and 16 studies in narrative synthesis. People with SMD who use tobacco should be offered combined pharmacological (Varenicline, Bupropion or Nicotine Replacement Therapy) and non-pharmacological interventions such as tailored directive and supportive behavioural interventions. For people with SMD and substance use disorders (drug and/or alcohol), interventions should be considered in accordance with WHO mhGAP guidelines. Prescribers should note potential drug-drug interactions. Recommendation were conditional and based on low/very low certainty of evidence with a scarcity of evidence from low- and middle-income settings. Conclusions: These guidelines mark an important step towards addressing premature mortality in people with SMD. The dearth of high-quality evidence and evidence from LMIC settings must inform the future research agenda