Perception of healthcare workers on mobile app-based clinical guideline for the detection and treatment of mental health problems in primary care: a qualitative study in Nepal.

BACKGROUND: In recent years, a significant change has taken place in the health care delivery systems due to the availability of smartphones and mobile software applications. The use of mobile technology can help to reduce a number of barriers for mental health care such as providers' workload, lack of qualified personnel, geographical and attitudinal barriers to seek treatment. This study assessed the perception of Nepali primary healthcare workers about the feasibility, acceptability, and benefits of using a mobile app-based clinical guideline for mental health care. METHOD: A qualitative study was conducted in two districts Chitwan and Ramechhap of Nepal with purposively selected medical officers (n = 8) and prescribing primary healthcare workers (n = 35) who were trained in the World Health Organization mental health Gap Action Program Intervention Guide. Semi-structured interviews and focus group discussions were conducted in Nepali, audio recorded, transcribed and translated into English for data analysis. Data were analysed manually using a thematic analysis approach. RESULTS: The majority of the healthcare workers and medical officers reported a high level of interest, motivation and positive attitudes towards the mobile app-based clinical guidelines for detection and treatment of people with mental disorders in primary care. They respondents suggested that several features and functions should be included in the app: suggestive diagnosis and treatment options; clinical data recording system; sending messages to patients to promote follow-up visits; allow offline functions; minimal typing options and content to be available in Nepali language. The study participants reported that the app could help in bringing uniformity in diagnosis and management of mental disorders across all health facilities, enabling remote supervision, helping verification of health workers' diagnosis and treatment; and increasing patients' trust in the treatment. Lack of reliable internet connection in health facilities, possibility of distracting interaction between patient and provider, and confidentiality were the key factors potentially hindering the use of the app. CONCLUSION: The suggested functions and features as well as the potential risk factors highlighted by the health workers, will be considered when further developing the mobile app-based clinical guidelines, training modality and materials, and the supervision system.

Predictors of receiving a diagnosis, referral and treatment of depression in people on antiretroviral therapy in South African primary care: a secondary analysis of data from a randomised trial.

OBJECTIVE: To describe the receipt of a diagnosis, referral and treatment for depression in people receiving antiretroviral therapy (ART), with depressive symptoms and attending primary care clinics in South Africa, and investigate factors associated with receiving these components of care. METHODS: This is a secondary analysis of data from a randomised controlled trial of an intervention intended to improve detection and treatment of depression in primary care patients receiving ART. In this analysis, we combined cross-sectional and longitudinal data from the intervention and control arms. Using regression models and adjusting for intra-cluster correlation of outcomes, we investigated associations between socioeconomic characteristics, depressive symptoms, stress, disability and stigma, and receipt of a diagnosis, referral and treatment for depression. RESULTS: Of 2002 participants enrolled, 18% reported a previous diagnosis of depression by a healthcare worker and 10% reported having received counselling from a specialist mental health worker. Diagnosis, referral and counselling during the follow-up period were appropriately targeted, being independently more frequent in participants with higher enrolment scores for depressive symptoms, stress or disability. Participants with higher stigma scores at enrolment were independently less likely to receive counselling. Severe socio-economic deprivation was common but was not associated with treatment. CONCLUSION: While the receipt of a diagnosis, referral and treatment for depression were uncommon, they seemed to be appropriately targeted. Socio-economic deprivation was not associated with treatment.

OBJECTIF: Décrire la réception d'un diagnostic, de l'orientation et du traitement pour la dépression chez les personnes recevant un traitement antirétroviral (ART), présentant des symptômes dépressifs et fréquentant des cliniques de soins primaires en Afrique du Sud, et étudier les facteurs associés à la réception de ces éléments de soins. MÉTHODES: Il s'agit ici d'une analyse secondaire des données d'un essai contrôlé randomisé d'une intervention destinée à améliorer la détection et le traitement de la dépression chez les patients sous ART dans les soins primaires. Dans cette analyse, nous avons combiné les données transversales et longitudinales des bras d'intervention et témoin. En utilisant des modèles de régression et en ajustant la corrélation intra-grappes des résultats, nous avons étudié les associations entre les caractéristiques sociodémographiques, les symptômes dépressifs, le stress, l'invalidité et la stigmatisation, et la réception d'un diagnostic, d'une orientation et d'un traitement pour la dépression. RÉSULTATS: Sur 2.002 participants inscrits, 18% ont déclaré un diagnostic antérieur de dépression par un agent de santé et 10% ont déclaré avoir reçu des conseils d'un agent spécialisé pour la santé mentale. Le diagnostic, l'orientation et le conseil pendant la période de suivi ont été ciblés de manière appropriée, étant indépendamment plus fréquents chez les participants ayant des scores d'inscription plus élevés pour les symptômes dépressifs, le stress ou l'invalidité. Les participants ayant des scores de stigmatisation plus élevés à l'inscription étaient indépendamment moins susceptibles de recevoir des conseils. La privation socioéconomique sévère était courante mais n'était pas associée au traitement. CONCLUSION: Bien que la réception d'un diagnostic, l'orientation et le traitement de la dépression soient rares, ils semblaient bien ciblés. La privation socioéconomique n'était pas associée au traitement.

Changing patterns of mental health knowledge in rural Kenya after intervention using the WHO mhGAP-Intervention Guide.

BACKGROUND: Despite the high prevalence of mental disorders, mental health literacy has been comparatively neglected. People's symptom-management strategies will be influenced by their mental health literacy. This study sought to determine the feasibility of using the World Health Organization mhGAP-Intervention Guide (IG) as an educational tool for one-on-one contact in a clinical setting to increase literacy on the specified mental disorders. METHODS: This study was conducted in 20 health facilities in Makueni County, southeast Kenya which has one of the poorest economies in Kenya. It has no psychiatrist or clinical psychologist. We recruited 3267 participants from a community that had already been exposed to community mental health services. We used Mental Health Knowledge Schedule to measure the changing patterns of mental health knowledge after a period of 3 months, following a training intervention using the WHO mhGAP-IG. RESULTS: Overall, there was a significant increase in mental health related knowledge [mean range 22.4-23.5 for both post-test and pre-test scores (p < 0.001)]. This increase varied with various socio-demographic characteristics such as sex, marital status, level of education, employment status and wealth index. CONCLUSIONS: mhGAP-IG is a feasible tool to increase mental health literacy in low-resource settings where there are no mental health specialists. Our study lends evidence that the WHO Mental Health Action Plan 2013-2020 and reduction of the treatment gap may be accelerated by the use of mhGAP-IG through improving knowledge about mental illness and potentially subsequent help seeking for early diagnosis and treatment.

Can mental health treatments help prevent or reduce intimate partner violence in low- and middle-income countries? A systematic review.

BACKGROUND: Epidemiological research suggests an interrelationship between mental health problems and the (re)occurrence of intimate partner violence (IPV). However, little is known about the impact of mental health treatments on IPV victimization or perpetration, especially in low- and middle-income countries (LMIC). METHODS: We conducted a systematic review to identify prospective, controlled studies of mental health treatments in LMIC. We defined 'mental health treatment' as an intervention for individuals experiencing mental ill health (including substance misuse) including a substantial psychosocial or pharmacological component. Studies had to measure a mental health and IPV outcome. We searched across multi-disciplinary databases using a structured search strategy. Screening of title/abstracts and full-text eligibility assessments were conducted by two researchers independently, data were extracted using a piloted spreadsheet, and a narrative synthesis was generated. RESULTS: We identified seven studies reported in 11 papers conducted in five middle-income countries. With the exception of blinding, studies overall showed acceptable levels of risk of bias. Four of the seven studies focused on dedicated mental health treatments in various populations, including: common mental disorders in earthquake survivors; depression in primary care; alcohol misuse in men; and alcohol misuse in female adult sex workers. The dedicated mental health treatments targeting depression or alcohol misuse consistently reduced levels of these outcomes. The two studies targeting depression also reduced short-term IPV, but no IPV benefits were identified in the two alcohol-focused studies. The other three studies evaluated integrated interventions, in which a focus on substance misuse was part of efforts to reduce HIV/AIDS and violence against particularly vulnerable women. In contrast to the dedicated mental health interventions, the integrated interventions did not consistently reduce mental ill health or alcohol misuse compared to control conditions. CONCLUSIONS: Too few studies have been conducted to judge whether mental health treatments may provide a beneficial strategy to prevent or reduce IPV in LMIC. Key future research questions include: whether promising initial evidence on the effects of depression interventions on reducing IPV hold more broadly, the required intensity of mental health components in integrated interventions, and the identification of mechanisms of IPV that are amenable to mental health intervention.

Socio-economic variations in the mental health treatment gap for people with anxiety, mood, and substance use disorders: results from the WHO World Mental Health (WMH) surveys.

BACKGROUND: The treatment gap between the number of people with mental disorders and the number treated represents a major public health challenge. We examine this gap by socio-economic status (SES; indicated by family income and respondent education) and service sector in a cross-national analysis of community epidemiological survey data. METHODS: Data come from 16 753 respondents with 12-month DSM-IV disorders from community surveys in 25 countries in the WHO World Mental Health Survey Initiative. DSM-IV anxiety, mood, or substance disorders and treatment of these disorders were assessed with the WHO Composite International Diagnostic Interview (CIDI). RESULTS: Only 13.7% of 12-month DSM-IV/CIDI cases in lower-middle-income countries, 22.0% in upper-middle-income countries, and 36.8% in high-income countries received treatment. Highest-SES respondents were somewhat more likely to receive treatment, but this was true mostly for specialty mental health treatment, where the association was positive with education (highest treatment among respondents with the highest education and a weak association of education with treatment among other respondents) but non-monotonic with income (somewhat lower treatment rates among middle-income respondents and equivalent among those with high and low incomes). CONCLUSIONS: The modest, but nonetheless stronger, an association of education than income with treatment raises questions about a financial barriers interpretation of the inverse association of SES with treatment, although future within-country analyses that consider contextual factors might document other important specifications. While beyond the scope of this report, such an expanded analysis could have important implications for designing interventions aimed at increasing mental disorder treatment among socio-economically disadvantaged people.

Interventions at the Transition from Prison to the Community for Prisoners with Mental Illness: A Systematic Review.

Prisoners have high rates of mental illness and the transition from prison to the community is a problematic time for the provision of mental health services and a range of negative outcomes have been identified in this period. A systematic review was conducted to identify interventions for prisoners with diagnosed mental health conditions that targeted this transition period. Fourteen papers from 13 research studies were included. The interventions identified in this review were targeted at different stages of release from prison and their content differed, ranging from Medicaid enrolment schemes to assertive community treatment. It was found that insurance coverage, and contact with mental health and other services can be improved by interventions in this period but the impact on reoffending and reincarceration is complex and interventions may lead to increased return to prison. There is a developing evidence base that suggests targeting this period can improve contact with community mental health and other health services but further high quality evidence with comparable outcomes is needed to provide more definitive conclusions. The impact of programmes on return to prison should be evaluated further to establish the effect of interventions on clinical outcomes and to clarify the role of interventions on reincarceration.

Mental health-related stigma and pathways to care for people at risk of psychotic disorders or experiencing first-episode psychosis: a systematic review.

BACKGROUND: Stigma associated with mental illness can delay or prevent help-seeking and service contact. Stigma-related influences on pathways to care in the early stages of psychotic disorders have not been systematically examined. METHOD: This review systematically assessed findings from qualitative, quantitative and mixed-methods research studies on the relationship between stigma and pathways to care (i.e. processes associated with help-seeking and health service contact) among people experiencing first-episode psychosis or at clinically defined increased risk of developing psychotic disorder. Forty studies were identified through searches of electronic databases (CINAHL, EMBASE, Medline, PsycINFO, Sociological Abstracts) from 1996 to 2016, supplemented by reference searches and expert consultations. Data synthesis involved thematic analysis of qualitative findings, narrative synthesis of quantitative findings, and a meta-synthesis combining these results. RESULTS: The meta-synthesis identified six themes in relation to stigma on pathways to care among the target population: 'sense of difference', 'characterizing difference negatively', 'negative reactions (anticipated and experienced)', 'strategies', 'lack of knowledge and understanding', and 'service-related factors'. This synthesis constitutes a comprehensive overview of the current evidence regarding stigma and pathways to care at early stages of psychotic disorders, and illustrates the complex manner in which stigma-related processes can influence help-seeking and service contact among first-episode psychosis and at-risk groups. CONCLUSIONS: Our findings can serve as a foundation for future research in the area, and inform early intervention efforts and approaches to mitigate stigma-related concerns that currently influence recognition of early difficulties and contribute to delayed help-seeking and access to care.

Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach.

BACKGROUND: Stigma related to mental health is a major barrier to help-seeking resulting in a large treatment gap in low- and middle-income countries (LMIC). This study assessed changes in knowledge, attitude and behaviour, and stigma related to help-seeking among participants exposed to an anti-stigma campaign. METHOD: The campaign, using multi-media interventions, was part of the SMART Mental Health Project, conducted for 3 months, across 42 villages in rural Andhra Pradesh, in South India. Mixed-methods evaluation was conducted in two villages using a pre-post design. RESULTS: A total of 1576 and 2100 participants were interviewed, at pre- and post-intervention phases of the campaign. Knowledge was not increased. Attitudes and behaviours improved significantly (p < 0.01). Stigma related to help-seeking reduced significantly (p < 0.05). Social contact and drama were the most beneficial interventions identified during qualitative interviews. CONCLUSION: The results showed that the campaign was beneficial and led to improvement of attitude and behaviours related to mental health and reduction in stigma related to help-seeking. Social contact was the most effective intervention. The study had implications for future research in LMIC.

Type 2 diabetes mellitus in people with severe mental illness: inequalities by ethnicity and age. Cross-sectional analysis of 588 408 records from the UK.

AIMS: To investigate whether the association of severe mental illness with Type 2 diabetes varies by ethnicity and age. METHODS: We conducted a cross-sectional analysis of data from an ethnically diverse sample of 588 408 individuals aged ≥18 years, registered to 98% of general practices (primary care) in London, UK. The outcome of interest was prevalent Type 2 diabetes. RESULTS: Relative to people without severe mental illness, the relative risk of Type 2 diabetes in people with severe mental illness was greatest in the youngest age groups. In the white British group the relative risks were 9.99 (95% CI 5.34, 18.69) in those aged 18-34 years, 2.89 (95% CI 2.43, 3.45) in those aged 35-54 years and 1.16 (95% CI 1.04, 1.30) in those aged ≥55 years, with similar trends across all ethnic minority groups. Additional adjustment for anti-psychotic prescriptions only marginally attenuated the associations. Assessment of estimated prevalence of Type 2 diabetes in severe mental illness by ethnicity (absolute measures of effect) indicated that the association between severe mental illness and Type 2 diabetes was more marked in ethnic minorities than in the white British group with severe mental illness, especially for Indian, Pakistani and Bangladeshi individuals with severe mental illness. CONCLUSIONS: The relative risk of Type 2 diabetes is elevated in younger populations. Most associations persisted despite adjustment for anti-psychotic prescriptions. Ethnic minority groups had a higher prevalence of Type 2 diabetes in the presence of severe mental illness. Future research and policy, particularly with respect to screening and clinical care for Type 2 diabetes in populations with severe mental illness, should take these findings into account.

Viewpoint survey of mental health service users' experiences of discrimination in England 2008-2014.

OBJECTIVE: Discrimination reported by mental health service users in England is high. The study aims to determine changes in mental health-related discrimination from 2008 to 2014. METHODS: Samples of mental health service users were interviewed from 2008 to 2014 using the Discrimination and Stigma Scale version 12. Social capital in terms of access to social resources is a marker of discrimination in terms of effects on social connections, and so from 2011, social capital also measured using the Resource Generator-UK. RESULTS: Fewer participants reported discrimination in one or more life areas in 2014 compared to 2008 (OR: 0.58, 95% CI 0.36 to 0.94 P = 0.03). A weighted multiple regression model found a decrease in overall discrimination in 2014 compared to 2008 (mean difference: -13.55, 95% CI: -17.32 to -9.78, P < 0.001). There was not a consistent in discrimination decline between each year. No differences in access to social resources were found. CONCLUSIONS: Discrimination has fallen significantly over 2008-2014, although there was not a consistent decline between years. There is no evidence that social capital has increased.

Public knowledge, attitudes, social distance and reported contact regarding people with mental illness 2009-2015.

OBJECTIVE: To investigate whether public knowledge, attitudes, desire for social distance and reported contact in relation to people with mental health problems have improved in England during the Time to Change (TTC) programme to reduce stigma and discrimination 2009-2015. METHODS: Using data from an annual face-to-face survey of a nationally representative sample of adults, we analysed longitudinal trends in the outcomes with regression modelling using standardised scores of the measures overall and by age and gender subgroups. RESULTS: There were improvements in all outcomes. The improvement for knowledge was 0.17 standard deviation units in 2015 compared to 2009 (95% CI 0.10, 0.23); for attitudes 0.20 standard deviation units (95% CI 0.14, 0.27) and for social distance 0.17 standard deviation units (95% CI 0.11, 0.24). Survey year for 2015 vs. 2009 was associated with a higher likelihood of reported contact (OR 1.32, 95% CI 1.13, 1.53). Statistically significant interactions between year and age suggest the campaign had more impact on the attitudes of the target age group (25-45) than those aged over 65 or under 25. Women's reported contact with people with mental health problems increased more than did men's. CONCLUSION: The results provide support for the effectiveness of TTC.

The economic costs of mental health-related discrimination.

OBJECTIVE: To estimate and compare the economic costs of mental health-related discrimination in the domains of health care, relationships and participation in leisure activities in England between 2011 and 2014. METHOD: A subsample of the Viewpoint survey was interviewed using the Costs of Discrimination Assessment Questionnaire in 2011 and 2014. Information on the impact of discrimination on healthcare use, help seeking from family and friends and participation in leisure activities was recorded. Pattern of contacts, costs and predictor of costs were examined. RESULTS: Our findings showed higher costs of health service use for individuals who reported experiences of discrimination in healthcare settings in 2011 compared with those who did not (mean difference £625, P-value 0.019). Individuals who reported experiences of discrimination in relationships in 2014 had higher healthcare costs than those who did not (mean difference £418, P -value 0.034). There was some evidence of a reduction in overall levels of healthcare use, leisure activities and support from families over time. Discrimination did not significantly affect help seeking from family/friends or leisure activities. CONCLUSION: There is some evidence that discrimination is related to increased healthcare costs. A prospective study is needed to better understand the consequences of these effects.

Qualitative analysis of mental health service users' reported experiences of discrimination.

OBJECTIVE: To better understand mental health service users' experiences of stigma and discrimination in different settings. METHOD: An annual telephone survey of people with a mental health diagnosis conducted to evaluate the Time to Change antistigma campaign in England. Of 985 people who participated in 2013, 84 took part in a qualitative interview which was audio recorded. Of these, 50 interviews were transcribed and thematically analysed to explore accounts of discrimination. We analysed common types of behaviour; motivations ascribed to the discriminators; expectations of what fair treatment would have been; and the impact of discrimination on participants. RESULTS: Discrimination was most common in five contexts: welfare benefits, mental health care, physical health care, family and friends. Participants often found it hard to assess whether a behaviour was discriminatory or not. Lack of support, whether by public services or by friends and family, was often experienced as discrimination, reflecting an expectation that positive behaviours and reasonable adjustments should be offered in response to mental health needs. CONCLUSION: The impact of discrimination across different settings was often perceived by participants as aggravating their mental health, and there is thus a need to treat discrimination as a health issue, not just a social justice issue.

Changes in newspaper coverage of mental illness from 2008 to 2014 in England.

OBJECTIVE: This study evaluates English newspaper coverage of mental health topics between 2008 and 2014 to provide context for the concomitant improvement in public attitudes and seek evidence for changes in coverage. METHOD: Articles in 27 newspapers were retrieved using keyword searches on two randomly chosen days each month in 2008-2014, excluding 2012 due to restricted resources. Content analysis used a structured coding framework. Univariate logistic regression models were used to estimate the odds of each hypothesised element occurring each year compared to 2008. RESULTS: There was a substantial increase in the number of articles covering mental health between 2008 and 2014. We found an increase in the proportion of antistigmatising articles which approached significance at P < 0.05 (OR = 1.21, P = 0.056). The decrease in stigmatising articles was not statistically significant (OR = 0.90, P = 0.312). There was a significant decrease in the proportion of articles featuring the stigmatising elements 'danger to others' and 'personal responsibility', and an increase in 'hopeless victim'. There was a significant proportionate increase in articles featuring the antistigmatising elements 'injustice' and 'stigma', but a decrease in 'sympathetic portrayal of people with mental illness'. CONCLUSION: We found a decrease in articles promoting ideas about dangerousness or mental illness being self-inflicted, but an increase in articles portraying people as incapable. Yet, these findings were not consistent over time.

Ethnicity and cardiovascular health inequalities in people with severe mental illnesses: protocol for the E-CHASM study.

PURPOSE: People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK. METHODS: E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers. RESULTS: In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)). CONCLUSIONS: There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.

Factors associated with experienced discrimination among people using mental health services in England.

BACKGROUND: Research has found considerable variation in how far individuals with a diagnosis of mental illness experience discrimination. AIMS: This study tested four hypotheses: (i) a diagnosis of schizophrenia will be associated with more discrimination than depression, anxiety or bipolar disorder; (ii) people with a history of involuntary treatment will report more discrimination than people without; (iii) higher levels of avoidance behaviour due to anticipated discrimination will be associated with higher levels of discrimination and (iv) longer time in contact with services will be associated with higher levels of discrimination. METHOD: Three thousand five hundred and seventy-nine people using mental health services in England took part in structured telephone interviews about discrimination experiences. RESULTS: A multiple regression model found that study year, age, employment status, length of time in mental health services, disagreeing with the diagnosis, anticipating discrimination in personal relationships and feeling the need to conceal a diagnosis from others were significantly associated with higher levels of experienced discrimination. CONCLUSION: Findings suggest that discrimination is not related to specific diagnoses but rather is associated with mental health problems generally. An association between unemployment and discrimination may indicate that employment protects against experiences of discrimination, supporting efforts to improve access to employment among people with a diagnosis of mental illness.

Evidence for effective interventions to reduce mental health-related stigma and discrimination in the medium and long term: systematic review.

BACKGROUND: Most research on interventions to counter stigma and discrimination has focused on short-term outcomes and has been conducted in high-income settings. AIMS: To synthesise what is known globally about effective interventions to reduce mental illness-based stigma and discrimination, in relation first to effectiveness in the medium and long term (minimum 4 weeks), and second to interventions in low- and middle-income countries (LMICs). METHOD: We searched six databases from 1980 to 2013 and conducted a multi-language Google search for quantitative studies addressing the research questions. Effect sizes were calculated from eligible studies where possible, and narrative syntheses conducted. Subgroup analysis compared interventions with and without social contact. RESULTS: Eighty studies (n = 422 653) were included in the review. For studies with medium or long-term follow-up (72, of which 21 had calculable effect sizes) median standardised mean differences were 0.54 for knowledge and -0.26 for stigmatising attitudes. Those containing social contact (direct or indirect) were not more effective than those without. The 11 LMIC studies were all from middle-income countries. Effect sizes were rarely calculable for behavioural outcomes or in LMIC studies. CONCLUSIONS: There is modest evidence for the effectiveness of anti-stigma interventions beyond 4 weeks follow-up in terms of increasing knowledge and reducing stigmatising attitudes. Evidence does not support the view that social contact is the more effective type of intervention for improving attitudes in the medium to long term. Methodologically strong research is needed on which to base decisions on investment in stigma-reducing interventions.

The link between mental health-related discrimination and suicidality: service user perspectives.

BACKGROUND: Suicide is a major global public health issue. Mental illness is a risk factor for suicide, but as many individuals with a diagnosed mental health problem do not experience suicidal ideation or attempt suicide, other individual and societal factors must be considered. Mental illness-related discrimination is one potential risk factor. METHOD: Using mixed methods, the influence of discrimination on suicidality amongst 194 individuals diagnosed with depression, bipolar or schizophrenia spectrum disorders was investigated. Qualitative interviews with a sub-sample of 58 individuals who reported a link between experience of discrimination and suicidality were analysed using framework analysis. Quantitative methods were used to examine the model derived from qualitative analyses. RESULTS: Results indicate that the experience of discrimination led 38% of the overall sample of 194 participants, to suicidal feelings and 20% reported that it contributed to making a suicide attempt. The qualitative model derived from interviews with a sub-sample of 58 participants suggested that the experience of discrimination is experienced as a stressor that exceeds coping resources, leading to a negative self-image and a perception of decreased supportive networks/social structure. The anticipation of further negative events and treatment, and the perception of a lack of supportive networks led individuals in this study to feelings of hopelessness and suicidality. Quantitative analyses provided support for the model. CONCLUSIONS: These data suggest that both psychological therapies aimed at improving coping skills and population-level anti-stigma interventions that reduce the occurrence of discrimination may provide some protection against suicide amongst individuals with mental health problems.

What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies.

BACKGROUND: Individuals often avoid or delay seeking professional help for mental health problems. Stigma may be a key deterrent to help-seeking but this has not been reviewed systematically. Our systematic review addressed the overarching question: What is the impact of mental health-related stigma on help-seeking for mental health problems? Subquestions were: (a) What is the size and direction of any association between stigma and help-seeking? (b) To what extent is stigma identified as a barrier to help-seeking? (c) What processes underlie the relationship between stigma and help-seeking? (d) Are there population groups for which stigma disproportionately deters help-seeking? METHOD: Five electronic databases were searched from 1980 to 2011 and references of reviews checked. A meta-synthesis of quantitative and qualitative studies, comprising three parallel narrative syntheses and subgroup analyses, was conducted. RESULTS: The review identified 144 studies with 90,189 participants meeting inclusion criteria. The median association between stigma and help-seeking was d = - 0.27, with internalized and treatment stigma being most often associated with reduced help-seeking. Stigma was the fourth highest ranked barrier to help-seeking, with disclosure concerns the most commonly reported stigma barrier. A detailed conceptual model was derived that describes the processes contributing to, and counteracting, the deterrent effect of stigma on help-seeking. Ethnic minorities, youth, men and those in military and health professions were disproportionately deterred by stigma. CONCLUSIONS: Stigma has a small- to moderate-sized negative effect on help-seeking. Review findings can be used to help inform the design of interventions to increase help-seeking.

How does a decision aid help people decide whether to disclose a mental health problem to employers? Qualitative interview study.

Background Decisions about whether to disclose mental health problems to employers are complex, with potential personal, employment and legal implications. Decision aids are evidence based tools, designed to help individuals make specific choices between treatment options. We previously developed a decision aid-Conceal Or ReveAL (CORAL)-to assist service users with decisions about disclosure to employers. As part of a mixed methods exploratory RCT, which demonstrated that the CORAL decision aid was effective in reducing decisional conflict, we aimed to explore its mechanism of action and to optimise the intervention for a future full scale trial. Methods In depth interviews were conducted with individuals receiving vocational support from a mental health trust and participating in the intervention arm of the pilot trial. Thematic analysis was conducted to identify the main themes relating to participants' perceptions of the CORAL decision aid. Results Thirteen participants were interviewed and five main themes were identified: sense of self and values; sense of control; anticipation of disclosure; experience of disclosure; and mechanism of action of the decision aid. Conclusions Data from our 13 participants suggest that the CORAL decision aid acts on several dimensions of decisional conflict: clarifying the pros and cons of different choices; increasing knowledge; structuring the decision making process; and clarifying needs and values. The current study indicated that it would be most effective when delivered by a professional well versed in employment and mental health matters such as a vocational adviser. The need for employers and policymakers to reduce the negative impact of disclosure is also highlighted.