A qualitative exploration of the perspectives of mental health professionals on stigma and discrimination of mental illness in Malaysia.

BACKGROUND: Stigma of mental illness has been identified as a significant barrier to help-seeking and care. Basic knowledge of mental illness - such as its nature, symptoms and impact - are neglected, leaving room for misunderstandings on mental health and 'stigma'. Numerous researches have been conducted on stigma and discrimination of people with mental disorders. However, most of the literature investigates stigma from a cultural conception point of view, experiences of patients or public attitudes towards mental illness but little to none from the standpoint of mental health professionals. In Malaysia, this research on stigma is particularly limited. Therefore, the state of stigma and discrimination of people with mental illness was investigated from the perspectives of mental health professionals in Malaysia. METHODS: In-depth, face-to-face, semi-structured interviews were conducted with 15 mental health professionals from both government and private sectors including psychiatrists, psychologists and counsellors. The interviews were approximately 45-minutes long. The data was subsequently analysed using the basic thematic approach. RESULTS: Seven principal themes, each with their own sub-themes, emerged from the analysis of 'stigma of mental illness' from mental health professionals' point of view, including: (1) main perpetrators, (2) types of mental illness carrying stigma, (3) demography and geography of stigma, (4) manifestations of stigma, (5) impacts of stigma, (6) causes of stigma and (7) proposed initiatives to tackle stigma. Stigma of mental illness is widespread in Malaysia. This is most evident amongst people suffering from conditions such as schizophrenia, bipolar disorder and depression. Stigma manifests itself most often in forms of labelling, rejection, social exclusion and in employment. Family, friends and workplace staff are reported to be the main perpetrators of discriminatory conducts. CONCLUSION: According to the perspectives of the mental health professionals, implications of stigma include patients being trapped in a vicious cycle of discrimination leading to detrimental consequences for the individual, their families, communities and society as a whole. There is a pressing need to address stigma of mental illness and its consequences, especially through raising awareness of mental health and wellbeing in Malaysia, as reported by the mental health professionals.This is the final published version of the article. It was originally published in the International Journal of Mental Health Systems (Hanafiah AN, Van Bortel T, International Journal of Mental Health Systems, 2015, 9:10 doi:10.1186/s13033-015-0002-1). The final version is available at http://dx.doi.org/10.1186/s13033-015-0002-

Perceived causes of mental illness and views on appropriate care pathways among Indonesians.

BackgroundThe mental health system in Indonesia comprises attempts to modernise a colonial relic. There is still a disconnect between available services and help-seeking behaviours at the grassroots level. This study aims to explore the perceptions of Javanese people on the aetiology of mental illness and their ideas on how to deal with individuals who may have mental illness.MethodsThis qualitative study involves semi-structured interviews, embedded in a cluster randomised trial examining the clinical and cost-effectiveness of primary mental health services. Interviews were conducted with Indonesian and Javanese. The recruitment procedure was aligned to the trial. Participants were primary care patients recruited from 21 sites across Yogyakarta province. Interviews were recorded, transcribed, and translated into English. Thematic analysis was used to analyse the interview transcripts.Results75 participants took part in the study: 51 women (68%) and 24 men (32%). Key themes emerged around perceived causes of mental health problems (including 'extrinsic factors'; 'intrinsic factors'; and 'spiritual factors'), and perceived appropriate pathways of care ('modern medical science'; 'social support and activities'; and 'religious or spiritual interventions'). Gender potentially influenced some of the responses.ConclusionsThemes indicate the variety of preconceptions towards mental health problems and assumptions regarding the best management pathways. Some of these preconceptions and assumptions support the utility of modern medical care, while the rest promote spiritual or religious healers. Participants' ideas of the appropriate care pathways largely correspond to their perception of what the symptoms are caused by. Despite hints to some understanding of the bio-psycho-social model of mental illness, most participants did not capture the complexity of mental health and illness, indicating the importance of contextual (especially culturally and religiously-aligned) public education around mental health, illness and care

Patient and public involvement (PPI) in prisons: the involvement of people living in prison in the research process - a systematic scoping review.

BACKGROUND: Patient and Public Involvement (PPI) in health and social care research is increasingly prevalent and is promoted in policy as a means of improving the validity of research. This also applies to people living in prison and using social care services. Whilst evidence for the effectiveness of PPI was limited and reviews of its application in prisons were not found, the infancy of the evidence base and moral and ethical reasons for involvement mean that PPI continues to be advocated in the community and in prisons. OBJECTIVES: To conduct a review of the literature regarding the involvement of people or persons living in prison (PLiP) in health and social care research focused on: (i) aims; (ii) types of involvement; (iii) evaluations and findings; (iv) barriers and solutions; and (v) feasibility of undertaking a systematic review. METHODS: A systematic scoping review was undertaken following Arksey and O'Malley's (International Journal of Social Research Methodology 8: 19-32, 2005) five-stage framework. A comprehensive search was conducted involving ten electronic databases up until December 2020 using patient involvement and context related search terms. A review-specific spreadsheet was created following the PICO formula, and a narrative synthesis approach was taken to answer the research questions. PRISMA guidelines were followed in reporting. RESULTS: 39 papers were selected for inclusion in the review. The majority of these took a 'participatory' approach to prisoner involvement, which occurred at most stages during the research process except for more 'higher' level research operations (funding applications and project management), and only one study was led by PLiPs. Few studies involved an evaluation of the involvement of PLiP, and this was mostly PLiP or researcher reflections without formal or independent analysis, and largely reported a positive impact. Barriers to the involvement of PLiP coalesced around power differences and prison bureaucracy. CONCLUSION: Given the very high risk of bias arising from the available 'evaluations', it was not possible to derive firm conclusions about the effectiveness of PLiP involvement in the research process. In addition, given the state of the evidence base, it was felt that a systematic review would not be feasible until more evaluations were undertaken using a range of methodologies to develop the field further

Silence of the limbs: pharmacological symptomatic treatment of intermittent claudication

Several oral "vasoactive" drugs claim to increase walking capacity in patients with intermittent claudication (IC). Naftidrofuryl, cilostazol, buflomedil, and pentoxifylline are the most studied molecules. Although spanning several decades, several studies underlying these claims were not properly designed, underpowered or showed clinically doubtful outcomes. The evidence for these "vasoactive" drugs has always been received with scepticism, creating the need for systematic reviews and meta-analyses. This brief review discusses the benefit-risk assessment of vasoactive drugs, by applying a systematic review to evaluate randomized, placebo-controlled trials. Oral naftidrofuryl and cilostazol have an acceptable safety profile as well as sustained evidence (documented by Cochrane analyses) of increased walking capacity. Subsequently, these drugs entered recommendations for peripheral arterial disease (PAD). In contrast, buflomedil and pentoxifylline have limited and/or doubtful evidence to increase walking capacity. Moreover, there were safety concerns about the narrow therapeutic range of buflomedil. Most other "vasoactive" drugs were either inappropriately or insufficiently tested or showed no significant if not negative effects on IC. "Vasoactive" drugs are no substitutes for lifestyle or exercise therapy but are adjuvant treatment to the well-appreciated triad of cardiovascular prevention (antiplatelet agents, statins and ACE-inhibitors), of which statins in their own right have documented claims to significantly increase walking capacity. "Vasoactive" drugs may have a place in the pharmacological management of symptomatic PAD in addition to the basic cardiovascular pharmacotherapy, when revascularization is not indicated, when exercise therapy is not feasible or when there is still insufficient benefit

Dementia-friendly prisons: a mixed-methods evaluation of the application of dementia-friendly community principles to two prisons in England.

OBJECTIVES: To apply and evaluate dementia-friendly community (DFC) principles in prisons. DESIGN: A pilot study and process evaluation using mixed methods, with a 1-year follow-up evaluation period. SETTING: Two male prisons: a category C sex offender prison (prison A) and a local prison (prison B). PARTICIPANTS: 68 participants-50 prisoners, 18 staff. INTERVENTION: The delivery of dementia information sessions, and the formulation and implementation of dementia-friendly prison action plans. MEASURES: Study-specific questionnaires; Alzheimer's Society DFC criteria; semi-structured interview and focus group schedules. RESULTS: Both prisons hosted dementia information sessions which resulted in statistically significant (p>0.05) increases in attendees' dementia knowledge, sustained across the follow-up period. Only prison A formulated and implemented a dementia action plan, although a prison B prisoner dedicated the prisoner magazine to dementia, post-information session. Prison A participants reported some progress on awareness raising, environmental change and support to prisoners with dementia in maintaining independence. The meeting of other dementia-friendly aims was less apparent. Numbers of older prisoners, and those diagnosed with dementia, appeared to have the greatest impact on engagement with DFC principles, as did the existence of specialist wings for older prisoners or those with additional care needs. Other barriers and facilitators included aspects of the prison institution and environment, staff teams, prisoners, prison culture and external factors. CONCLUSIONS: DFC principles appear to be acceptable to prisons with some promising progress and results found. However, a lack of government funding and strategy to focus action around the escalating numbers of older prisoners and those living with dementia appears to contribute to a context where interventions targeted at this highly vulnerable group can be deprioritised. A more robust evaluation of this intervention on a larger scale over a longer period of time would be useful to assess its utility further

An intervention to improve mental health care for conflict-affected forced migrants in low-resource primary care settings: a WHO MhGAP-based pilot study in Sri Lanka (COM-GAP study).

BACKGROUND: Inadequacy in mental health care in low and middle income countries has been an important contributor to the rising global burden of disease. The treatment gap is salient in resource-poor settings, especially when providing care for conflict-affected forced migrant populations. Primary care is often the only available service option for the majority of forced migrants, and integration of mental health into primary care is a difficult task. The proposed pilot study aims to explore the feasibility of integrating mental health care into primary care by providing training to primary care practitioners serving displaced populations, in order to improve identification, treatment, and referral of patients with common mental disorders via the World Health Organization Mental Health Gap Action Programme (mhGAP). METHODS/DESIGN: This pilot randomized controlled trial will recruit 86 primary care practitioners (PCP) serving in the Puttalam and Mannar districts of Sri Lanka (with displaced and returning conflict-affected populations). The intervention arm will receive a structured training program based on the mhGAP intervention guide. Primary outcomes will be rates of correct identification, adequate management based on set criteria, and correct referrals of common mental disorders. A qualitative study exploring the attitudes, views, and perspectives of PCP on integrating mental health and primary care will be nested within the pilot study. An economic evaluation will be carried out by gathering service utilization information. DISCUSSION: In post-conflict Sri Lanka, an important need exists to provide adequate mental health care to conflict-affected internally displaced persons who are returning to their areas of origin after prolonged displacement. The proposed study will act as a local demonstration project, exploring the feasibility of formulating a larger-scale intervention study in the future, and is envisaged to provide information on engaging PCP, and data on training and evaluation including economic costs, patient recruitment, and acceptance and follow-up rates. The study should provide important information on the WHO mhGAP intervention guide to add to the growing evidence base of its implementation. TRIAL REGISTRATION: SLCTR/2013/025

WHO guidance on mental health training: a systematic review of the progress for non-specialist health workers.

OBJECTIVE: To assess existing literature on the effectiveness of mental health training courses for non-specialist health workers, based on the WHO guidelines (2008). DESIGN: A systematic review was carried out, complying with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. DATA SOURCES: After examination of key studies in the literature, a comprehensive search was performed within the following electronic databases on 31 May 2017: PubMed, PsycINFO, CINAHL (using EBSCOHost interface), Cochrane, Web of Science. ELIGIBILITY CRITERIA: Searches were conducted for articles published in English from January 2008 to May 2017, using search terms related to mental health, training, community care and evaluation/outcome, following the Participants, Interventions, Comparators and Outcomes process for evidence-based practice. OUTCOMES: Data were collected across the following categories: trainees (number and background), training course (curriculum, teaching method, length), evaluation method (timing of evaluation, collection method and measures assessed) and evaluation outcome (any improvement recorded from baseline). In addition, studies were assessed for their methodological quality using the framework established by Liu et al (2016). RESULTS: 29 studies with relevant training courses met the inclusion criteria. These were implemented across 16 countries since 2008 (over half between 2014 and 2017), with 10 in three high-income countries. Evaluation methods and outcomes showed high variability across studies, with courses assessing trainees' attitude, knowledge, clinical practice, skills, confidence, satisfaction and/or patient outcome. All 29 studies found some improvement after training in at least one area, and 10 studies found this improvement to be significant. CONCLUSIONS: Training non-specialist workers in mental healthcare is an effective strategy to increase global provision and capacity, and improves knowledge, attitude, skill and confidence among health workers, as well as clinical practice and patient outcome. Areas for future focus include the development of standardised evaluation methods and outcomes to allow cross-comparison between studies, and optimisation of course structure. PROSPERO REGISTRATION NUMBER: CRD42016033269