Stigma as a barrier to recognizing personal mental illness and seeking help: a prospective study among untreated persons with mental illness.

It is unclear to what extent failure to recognize symptoms as potential sign of a mental illness is impeding service use, and how stigmatizing attitudes interfere with this process. In a prospective study, we followed a community sample of 188 currently untreated persons with mental illness (predominantly depression) over 6 months. We examined how lack of knowledge, prejudice and discrimination impacted on self-identification as having a mental illness, perceived need, intention to seek help, and help-seeking, both with respect to primary care (visiting a general practitioner, GP) and specialist care (seeing a mental health professional, MHP). 67% sought professional help within 6 months. Fully saturated path models accounting for baseline depressive symptoms, previous treatment experience, age and gender showed that self-identification predicted need (beta 0.32, p < 0.001), and need predicted intention (GP: beta 0.45, p < 0.001; MHP: beta 0.38, p < 0.001). Intention predicted service use with a MHP after 6 months (beta 0.31, p < 0.01; GP: beta 0.17, p = 0.093). More knowledge was associated with more self-identification (beta 0.21, p < 0.01), while support for discrimination was associated with lower self-identification (beta - 0.14, p < 0.05). Blaming persons with mental illness for their problem was associated with lower perceived need (beta - 0.16, p < 0.05). Our models explained 37% of the variance of seeking help with a MHP, and 33% of help-seeking with a GP. Recognizing one's own mental illness and perceiving a need for help are impaired by lack of knowledge, prejudice, and discrimination. Self-identification is a relevant first step when seeking help for mental disorders.

Title: Brief Implicit Association Tests of Stigmatizing Attitudes, Awareness of Mental Distress and Label-Avoidance: A Study in People with Depressive Symptoms.

This study aims to develop and implement brief implicit association tests (BIATs) assessing stigmatizing attitudes towards mental illness, awareness of mental distress and self-identification as having a mental illness. We recruited 229 people (age range 18-80 years) with currently untreated depressive symptoms. In addition to BIATs, explicit measures assessed depression severity, contact experience and self-identification as having a mental illness. BIATs showed good feasibility. Age and educational differences were observed for each BIAT. Regarding depression severity, people with mild depression severity showed stronger implicit label-avoidance. Novel BIATs proved feasible and future research should investigate the predictive value of implicit measures on help seeking in people with mental illness.

Writing interventions in older adults and former children of the World War II: impact on quality of life and depression.

OBJECTIVES: The aim of the current study was to analyze whether biographical writing interventions have an impact on depression and QoL compared to daily diary writing. We also wanted to investigate differential effects between structured and unstructured interventions. METHOD: In two Northern regions of Germany, 119 older adults aged 64-90 were randomly assigned to three different types of narrative writing interventions: written structured and unstructured biographical disclosure as well as daily diary writing. Depression (PHQ-9), QoL (SF-12, EUROHIS) and trauma-related symptoms (PCL-C) were obtained pre- and post-interventions as well as at three-month follow-up. RESULTS: Follow-up measures were obtained from 85 participants (29% loss to follow-up; mean age = 73.88; 68.2% female). Results of repeated measurement analysis demonstrated a significant effect on depression with the daily diary writing group showing lower depressive symptoms than structured biographical writing. We did not find a significant impact on QoL. Post-hoc analyses showed that posttraumatic symptoms lead to increases in depressive symptoms. CONCLUSION: In a non-clinical sample of community-dwelling older adults, biographical writing interventions were not favorable to daily diary writing concerning the outcomes of the study. This might be related to the association of traumtic reminiscences of former children of World War II and outcome measures.

The Stigma of Mental Illness as a Barrier to Self Labeling as Having a Mental Illness.

The aim of this study was to investigate whether personal stigma decreases self-identification as having a mental illness in individuals with untreated mental health problems. We interviewed 207 persons with a currently untreated mental health problem as confirmed by a structured diagnostic interview. Measures included symptom appraisal, self-identification as having a mental illness (SELFI), self-labeling (open-ended question on the nature of their problem) stigma-related variables (explicit and implicit), as well as sociodemographics, current symptom severity, and previous treatment. Support for discrimination and implicit stigmatizing attitude were both associated with lower likelihood of self-identification. More social distance and support for discrimination were associated with less self-labeling. Previous treatment was the strongest predictor of symptom appraisal, SELFI, and self-labeling. Destigmatizing mental illness could increase awareness of personal mental health problems, potentially leading to lower rates of untreated mental illness.

The impact of forced displacement in World War II on mental health disorders and health-related quality of life in late life - a German population-based study.

BACKGROUND: Long-term effects of World War II experiences affect psychological and physical health in aged adults. Forced displacement as a traumatic event is associated with increased psychological burden even after several decades. This study investigates the contribution of forced displacement as a predictor for mental health disorders and adds the aspect of health-related quality of life (QoL). METHOD: A sample of 1,659 German older adults aged 60-85 years was drawn from a representative survey. Post-traumatic stress disorder (PTSD), somatoform symptoms, depressive syndromes, and health-related QoL were assessed as outcome variables. Chi-square and t-test statistics examined differences between displaced and non-displaced people. Logistic regression analyses were performed to examine the impact of forced displacement on mental health disorders and QoL. RESULTS: Displaced people reported higher levels of PTSD, depressive and somatoform symptoms, and lower levels of health-related QoL. Displacement significantly predicted PTSD and somatoform symptoms in late life, but not depressive disorders. Health-related QoL was predicted by forced displacement and socio-demographic variables. CONCLUSION: Forced displacement is associated with an elevated risk for PTSD and somatoform symptoms and lowered health-related QoL in aged adults. Its unique impact declines after including socio-demographic variables. Long-term consequences of forced displacement need further investigations and should include positive aspects in terms of resilience and protective coping strategies.

[How traumatized are the children of World War II? The relationship of age during flight and forced displacement and current posttraumatic stress symptoms]. / Wie traumatisiert sind die Kinder des 2. Weltkrieges? Der Zusammenhang von Alter bei Flucht und Vertreibung und aktuellen posttraumatischen Belastungssymptomen.

Traumatic events experienced in childhood can be reactivated in older age. The present study investigates the relation of age during flight and forced displacement within World War II (WWII; 2-7 years, 8-13 years, 14-20 years) and the current occurrence of posttraumatic stress disorder (PTSD). Traumatic events and current posttraumatic stress symptoms were assessed by the Harvard Trauma Questionnaire and the Impact of Event Scale-revised. Mean age of participants (N=169) was 73.76 years (SD=4.18). The eldest group reported most war-related traumatic events. In each age group a one-week-prevalence for a full PTSD of 10-11% was found. The prevalence for both full and subthreshold PTSD was higher for the age group 14-20 years (60.5%) compared to the younger age groups (33-35%). People, who experienced WWII as adolescents, show a dose-response-effect indicated by a higher prevalence for subthreshold PTSD.

Authors should clearly report how they derived the overall rating when applying AMSTAR 2-a cross-sectional study.

OBJECTIVES: A measurement tool to assess systematic reviews (SRs) 2 (AMSTAR 2) allows for deriving the overall confidence in an SR. We investigated how authors derived the overall confidence rating and whether different schemes lead to different results. STUDY DESIGN AND SETTING: We compared three different schemes (original 7-item scheme, a self-developed 5-item scheme, and the AMSTAR Web site) to derive the overall confidence in AMSTAR 2 using two distinct samples of SRs. Multiple bibliographic databases were searched for articles to analyze how AMSTAR 2 was applied by others. RESULTS: In both samples (n = 60 and n = 58), the Friedman test revealed a significant difference between the schemes (P < 0.001). The Web site scheme was the least strict one, whereas between the 5-item and 7-item scheme, no differences were found in post hoc analyses. We included 53 publications applying AMSTAR 2 identified in our literature search. Only 37 of them (70%) used the original 7-item scheme. Less than half of them (18 of 37) reported how they derived the overall rating. CONCLUSION: Authors should clearly report how they have derived the overall rating when applying AMSTAR 2. Reporting should allow for reproducing the overall ratings for editors, peer reviewers, and readers.

[GRADE guidelines: 18. How ROBINS-I and other tools to assess risk of bias in nonrandomized studies should be used to rate the certainty of a body of evidence]. / GRADE-Leitlinien: 18. Wie ROBINS-I und andere Instrumente zur Einschätzung des Risikos für Bias von nicht-randomisierten Studien verwendet werden sollten, um die Vertrauenswürdigkeit eines Evidenzkörpers zu bewerten.

OBJECTIVE: To provide guidance on how systematic review authors, guideline developers, and health technology assessment practitioners should approach the use of the risk of bias in nonrandomized studies of interventions (ROBINS-I) tool as a part of GRADE's certainty rating process. STUDY DESIGN AND SETTING: The study design and setting comprised iterative discussions, testing in systematic reviews, and presentation at GRADE working group meetings with feedback from the GRADE working group. RESULTS: We describe where to start the initial assessment of a body of evidence with the use of ROBINS-I and where one would anticipate the final rating would end up. The GRADE accounted for issues that mitigate concerns about confounding and selection bias by introducing the upgrading domains: large effects, dose-effect relations, and when plausible residual confounders or other biases increase certainty. They will need to be considered in an assessment of a body of evidence when using ROBINS-I. CONCLUSION: The use of ROBINS-I in GRADE assessments may allow for a better comparison of evidence from randomized controlled trials (RCTs) and nonrandomized studies (NRSs) because they are placed on a common metric for risk of bias. Challenges remain, including appropriate presentation of evidence from RCTs and NRSs for decision-making and how to optimally integrate RCTs and NRSs in an evidence assessment.

Validity and psychometric properties of the Self-Identification as Having a Mental Illness Scale (SELF-I) among currently untreated persons with mental health problems.

Conceptualizing own symptoms as potential signs of a mental illness is an important, yet under-researched step towards appropriate help. Few validated measures address recognition and identification of own mental illness. Aim of this study is to investigate performance and correlates of the 'Self-Identification as Having a Mental Illness' scale (SELF-I) in a group of 229 currently untreated individuals with mental health problems, predominantly depression. Measures included: self-identification with having a mental illness (SELF-I), depressive and somatic symptom severity (PHQ-9 and PHQ-15), illness perceptions (B-IPQ-R-C), and sociodemographic variables. Principal-component analysis revealed in a unidimensional factor structure. The SELF-I showed good reliability in terms of internal consistency (Cronbach's alpha, 0.85-0.87) and re-test reliability over three months (Intraclass correlation coefficient, 0.74). Associations with depressive symptoms, previous treatment experiences and self-labelling demonstrated construct and criterion validity. Low associations with somatic symptoms and with illness-perceptions as measured by the B-IPQ-R-C indicated discriminant validity. We did not observe any floor or ceiling effects. The SELF-I scale is a brief, unidimensional and reliable measure of self-identification as having a mental illness that offers useful research perspectives.

[Depression Literacy - German Translation and Testing of the Depression Literacy Scale]. / Depressionswissen ­ Deutsche Übersetzung und Testung der Depression Literacy Scale.

OBJECTIVE: Translation and psychometric testing of a German adaptation of the Australian Depression Literacy Scale. METHODS: Translation of the Depression Literacy Scale by Griffith et al. (2004) into German and testing for depression literacy in a sample of 229 people with depressive syndrome. RESULTS: The investigated sample had a mean age of 49.4 years (18 - 80 years). On average, 51 % of the 22 questions were correctly answered. The scale showed a satisfactory internal consistency with α = .74. The first-time application of the translated D-Lit German scale showed significant differences in subgroup analyzes of sex, age, and education. Hence, women, younger persons and persons with a higher school education reported higher values on the Depression Literacy Scale. CONCLUSION: The translation of the Depression Literacy Scale (D-Lit German) resulted in an easy-to-understand and applicable questionnaire. Items relating to therapeutic and drug-related treatments of depressen were more difficult to answer. The D-Lit scale proved to be a reliable and economic instrument for the investigation of depression literacy. Future studies should include depression literacy in investigations on the demands and help-seeking behaviour of people with depression.

Associations between causal attributions and personal stigmatizing attitudes in untreated persons with current mental health problems.

Past research has shown that among the general public, certain causal explanations like biomedical causes are associated with stronger desire for social distance from persons with mental illness. Aim of this study was to find out how different causal attributions of persons with untreated mental health problems regarding their own complaints are associated with stigmatizing attitudes, anticipated self-stigma when seeking help and perceived stigma-stress. Altogether, 207 untreated persons with a current depressive syndrome were interviewed. Biomedical causes, but also belief in childhood trauma or unhealthy behavior as a cause of the problem, were associated with stronger personal stigma and with more stigma-stress. Similarities and differences to findings among the general population and implications for future research are discussed.

Psychosocial Correlates of Frailty in Older Adults.

BACKGROUND: The aim of this study was to investigate psychosocial variables associated with frailty status. Moreover, gender differences in the psychosocial variables associated with frailty were examined. METHODS: This cross-sectional study examined a community-dwelling sample of N = 210 older adults (M = 75.31 years). Frailty was measured with the Tilburg Frailty Indicator. Quality of life, depression, resilience, social support, self-efficacy, traumata experienced, and trauma severity were assessed as psychosocial variables. Logistic regression analyses were performed. RESULTS: In total, 41.4% of the participants were frail (49.6% women, 27.8% men). Main correlates of frailty were depressive symptoms, quality of life, and resilience. Gender differences for frailty correlates were found. Depressive symptoms and perceived social support were mainly associated with frailty in women. Furthermore, age was only significantly associated with frailty in women. Quality of life was significantly associated with frailty being a protective factor in both women and men. Trauma count and trauma severity were associated with an elevated risk for frailty in men. CONCLUSIONS: The results show that the psychosocial variables depressive symptoms, quality of life, and resilience are associated with frailty. Gender-specific differences in psychosocial correlates of frailty were revealed. Results suggest that gender-specific assessments and interventions should be developed to prevent frailty in late life.