Promoting stigma coping and empowerment in patients with schizophrenia and depression: results of a cluster-RCT.

There is a need for interventions supporting patients with mental health conditions in coping with stigma and discrimination. A psycho-educational group therapy module to promote stigma coping and empowerment (STEM) was developed and tested for efficacy in patients with schizophrenia or depression. 30 clinical centers participated in a cluster-randomized clinical trial, representing a broad spectrum of mental health care settings: in-patient (acute treatment, rehabilitation), out-patient, and day-hospitals. As randomized, patients in the intervention group clusters/centers received an illness-specific eight sessions standard psychoeducational group therapy plus three specific sessions on stigma coping and empowerment ('STEM'). In the control group clusters the same standard psychoeducational group therapy was extended to 11 sessions followed by one booster session in both conditions. In total, N = 462 patients were included in the analysis (N = 117 with schizophrenia spectrum disorders, ICD-10 F2x; N = 345 with depression, ICD-10 F31.3-F31.5, F32-F34, and F43.2). Clinical and stigma-related measures were assessed before and directly after treatment, as well as after 6 weeks, 6 months, and 12 months (M12). Primary outcome was improvement in quality of life (QoL) assessed with the WHO-QOL-BREF between pre-assessment and M12 analyzed by mixed models and adjusted for pre-treatment differences. Overall, QoL and secondary outcome measures (symptoms, functioning, compliance, internalized stigma, self-esteem, empowerment) improved significantly, but there was no significant difference between intervention and control group. The short STEM module has proven its practicability as an add-on in different settings in routine mental health care. The overall increase in empowerment in both, schizophrenia and depression, indicates patients' treatment benefit. However, factors contributing to improvement need to be explored.The study has been registered in the following trial registers. ClinicalTrials.gov: https://register.clinicaltrials.gov/ Registration number: NCT01655368. DRKS: https://www.drks.de/drks_web/ Registration number: DRKS00004217.

Stigma experiences and perceived stigma in patients with first-episode schizophrenia in the course of 1 year after their first in-patient treatment.

Patients with schizophrenia suffer from stigma and discrimination due to their illness. Yet it is not well examined how experiences of stigma and discrimination express at the early illness stage and how they develop subsequently. Therefore, clinical and psycho-social correlates of stigma experiences and perceived stigma are analyzed in patients with first-episode schizophrenia over the course of 1 year after their first in-patient treatment. Questionnaire data assessed within the multi-centre-RCT "First-Episode Study" of the German Research Network on Schizophrenia were analyzed. Patients with first-episode schizophrenia were assessed 8 weeks after their first in-patient treatment (post-acute assessment) and 1 year later. N = 48 (post-acute) and N = 24 (1-year follow-up) patients provided questionnaire data appropriate for analyses, with N = 12 dyads. These data included burden due to stigma experiences (B-STE), perceived stigma (PDDQ), clinical (PANSS, CDSS, CGI, GAF, SAS) and psycho-social factors (LQLP, FSNK-self-esteem, KK-Scale). Cross-lag-correlation models showed a causal relation between stigma experiences (post-acute) and reduced self-esteem after 1 year. Multiple regression models revealed different models for experienced and perceived stigma. Factors associated with higher stigma experiences were older age, worse clinical global impression, better social adjustment, lower self-esteem, and the belief that illness is not driven by chance or fate. The different associations between psycho-social factors and stigma experiences and perceived stigma demonstrate the complexity of this inter-relationship. The results have practical implications for psycho-educational and other therapeutic interventions addressing stigma coping. Since the sample was small and selective, replication studies are needed.

Prevalence of psychiatric diagnoses in asylum seekers with follow-up.

BACKGROUND: In the study, the frequency and nature of asylum seekers' psychiatric diagnoses in a German admission center were examined. Additional aims were to identify changes in those diagnoses over time and to investigate health care utilization of mentally ill asylum seekers in the community. METHODS: The sample for the study "Psychiatric Examination of Asylum Seekers" in Bavaria consisted of a total of 283 asylum seekers and included 2 subsamples: help-seeking individuals and a randomly selected group. 34 of all asylum seekers were part of an extensive psychiatric follow-up examination (t2) about six months after the first examination (t1). Here, we used psychometric tools and a psychiatric interview by a medical doctor and a psychologist with the help of translators. RESULTS: 79% of help-seekers and 45% of the random group received at least one psychiatric diagnosis at t1. The most frequent diagnoses were trauma- and stress-related disorders, affective disorders, and insomnia. Men and Muslims were underrepresented in the help-seeking group. In the follow-up subsample, the rate of psychiatric diagnoses went down from 74% at t1 to 38% at t2. In contrast, the number of PTSD cases increased from 4 at t1 to 7 at t2. The severity of PTSD symptoms such as hyperarousal and avoidance also increased. Of the 13 persons in the follow-up-sample diagnosed with depression at t1, only 2 still fit the criteria of the disease at t2. Only 5 subjects had received some sort of psychotherapy or counseling. CONCLUSION: The prevalence of mental illness in asylum seekers reported here corresponds to the usual range in the literature. It is significantly higher than in European civil society, especially regarding PTSD. At t2, the diagnoses of PTDS had increased within several months without evident additional traumatic events. Asylum seekers' psychiatric diagnoses soon after arrival should be recorded carefully and examination should be repeated after six months. The psychiatric and psychotherapeutic treatment of asylum seekers is still insufficient. Psychoeducative steps should be taken to relieve the stigma on mental illness, especially among males and Muslims.

Stigmatization of psychiatrists and general practitioners: results of an international survey.

The stigma of mental illness affects psychiatry as a medical profession and psychiatrists. The present study aimed to compare the extent and correlation patterns of perceived stigma in psychiatrists and general practitioners. An international multicenter survey was conducted in psychiatrists and general practitioners from twelve countries. Responses were received from N = 1,893 psychiatrists and N = 1,238 general practitioners. Aspects of stigma assessed in the questionnaire included perceived stigma, self-stigma (stereotype agreement), attitudes toward the other profession, and experiences of discrimination. Psychiatrists reported significantly higher perceived stigma and discrimination experiences than general practitioners. Separate multiple regression analyses showed different predictor patterns of perceived stigma in the two groups. Hence, in the psychiatrists group, perceived stigma correlated best with discrimination experiences and self-stigma, while in the general practitioners group it correlated best with self-stigma. About 17% of the psychiatrists perceive stigma as a serious problem, with a higher rate in younger respondents. Against this background, psychiatry as a medical profession should set a high priority on improving the training of young graduates. Despite the number of existing antistigma interventions targeting mental health professionals and medical students, further measures to improve the image of psychiatry and psychiatrists are warranted, in particular improving the training of young graduates with respect to raising awareness of own stigmatizing attitudes and to develop a better profession-related self-assertiveness.

Measuring the stigma of psychiatry and psychiatrists: development of a questionnaire.

The stigma of mental illness is a severe burden for people suffering from mental illness both in private and public life, also affecting their relatives, their close social network, and the mental health care system in terms of disciplines, providers, and institutions. Interventions against the stigma of mental illness employ complementary strategies (e.g., protest, education, and contact) and address different target groups (e.g., school children and teachers, journalists, stakeholders). Within this framework, the World Psychiatric Association has adopted an Action Plan with the goal to improve the image of psychiatry and to reduce potential stigmatizing attitudes toward psychiatry and psychiatrists. To evaluate such interventions, a questionnaire has been developed that assesses opinions and attitudes toward psychiatrists and psychiatry in different samples of medical specialists (psychiatrists and general practitioners). The questionnaire comprises scales about perceived stigma in terms of the perception of societal stereotypes, self-stigma in terms of stereotype agreement, perceived stigma in terms of structural discriminations, discrimination experiences, stigma outcomes, and attitudes toward a second medical discipline. It is available in several languages (Arab, English, German, Japanese, Polish, and Spanish) and can easily be adapted for utilization in other medical specialties.

Evaluation of the German WPA "program against stigma and discrimination because of schizophrenia--Open the Doors": results from representative telephone surveys before and after three years of antistigma interventions.

OBJECTIVES: In 2001, the World Psychiatric Association's global antistigma-program "Fighting stigma and discrimination because of schizophrenia--Open the Doors" was initiated in Germany. Several measures to tackle the stigma in certain target populations have been proven successful, but the effectiveness of the program on the general population level has not yet been examined. METHODS: Before the start of a number of antistigma interventions in 2001, a professional survey institute was commissioned to conduct a representative telephone survey in 6 German cities (N=7225). The cities were chosen with respect to the implementation of antistigma programs (Düsseldorf, Munich), awareness programs (Bonn, Cologne; with the aim to enhance early recognition of schizophrenia), and none of the programs (Berlin, Essen). A panel design follow-up survey (N=4622) was conducted in 2004. Stereotypes, beliefs and attitudes about schizophrenia and social distance--i.e. the distance between different groups of society--towards people with schizophrenia, and the knowledge of antistigma projects were assessed. RESULTS: Overall, social distance decreased significantly between 2001 and 2004 (p=0.001). At the city level, this effect was only significant in those cities where antistigma projects were implemented (p<0.001), although the observed attitude changes were small. In cities with antistigma projects, social distance primarily decreased in the social distance subscale "transient social relations" (p<0.001), but not in the subscale "closer social relations". Both subcales did not change significantly in cities without antistigma projects. DISCUSSION: The present study provides limited evidence for the efficacy of antistigma interventions on the population level in Germany. Further research is needed to separate direct effects of antistigma interventions from more general, indirect influences on social distance.