Factors predicting help seeking for mental illness among college students.

BACKGROUND: Evidence supports the contribution of various stigma-related constructs to help-seeking. These constructs have yet to be tested in a single model among college students, a group highly affected by mental illness. AIMS: Using data from 153 college students, this study examines factors contributing to help seeking for mental illness. METHOD: Using path analysis, the current study evaluated a model of the relationship between level of familiarity, personal stigma, desired social distance, label avoidance, attitudes towards treatment seeking and intentions to seek treatment. RESULTS: Findings support a model of help-seeking describing the relationship between familiarity with mental illness, personal stigma, social distance, label avoidance, attitudes and intentions to seek treatment. CONCLUSIONS: Findings suggest label avoidance, attitudes towards treatment seeking and intentions to seek treatment might be augmented through interventions aimed at increasing college students' levels of familiarity, or intimate contact, with individuals with mental illness. Additional implications for practice and further research are addressed.

Who Comes Out With Their Mental Illness and How Does It Help?

Coming out with mental illness may be an effective strategy for reducing self-stigma. This study examined predictors and consequences of coming out. Participants (N = 106) with severe mental illness who reported being out (n = 79) or not out (n = 27) endorsed benefits of being out (BBOs) and reasons for staying in. Predictors from baseline measures were self-stigma, insight, and psychiatric diagnosis. Three outcome measures-basic psychological needs, care engagement, and depression-were also completed at baseline and 1-month follow-up. Among participants already out, BBOs and reasons for staying in were significantly and independently associated with self-stigma, insight, and lifetime affective diagnoses. In terms of consequences, BBOs were associated with cross-sectional and 1-month measures of engagement for those already out, but not for closeted participants. Among closeted participants, BBOs were associated with baseline and 1-month measures of basic psychological needs. Implications for strategies meant to promote disclosure in order to decrease self-stigma are considered.

The California Assessment of Stigma Change: A Short Battery to Measure Improvements in the Public Stigma of Mental Illness.

Contact-based anti-stigma programs delivered by people with lived experience yields stigma change. This study examined psychometrics and sensitivity of the California Assessment of Stigma Change (CASC). CASC assesses prejudicial beliefs, affirming attitudes, and willingness to seek mental healthcare. Four samples, two high school groups, college students, and hotel desk clerks, completed CASC immediately before and after a contact-based program. Two samples completed follow-up: one of the high school groups and the college students. CASC assesses stigma with a 9-item Attribution Questionnaire (AQ9), personal empowerment with a 3-item scale (ES), recovery orientation with a 3-item scale (RS), and psychological help seeking willingness with a 6-item questionnaire (CSQ). Internal consistencies ranged adequate to satisfactory for AQ9, ES, and CSQ. Concurrent validity was partially supported. Change sensitivity was demonstrated among at least half of each construct's analyses. CASC seems a psychometrically valid way to efficiently monitor attitudinal and care seeking intentions changes. Outcome monitoring can strengthen contact-based anti-stigma programs, an emerging evidence-based practice.

Changing stigma through a consumer-based stigma reduction program.

This study assessed the Anti-Stigma Project workshop, a contact/education intervention developed by On Our Own of Maryland, Inc. and the Maryland Mental Hygiene Administration. Two separate randomized controlled trials administered pre- and post-test questionnaire assessments. One included people with mental illness (N = 127) and a second included mental health providers (N = 131). Post-intervention, people with mental illness were more aware of stigma, had lower levels of prejudice, and increased belief in recovery. Providers were more aware of stigma, had lower levels of prejudice, and increased concurrence in self-determination of people with mental illness. Increasing providers' stigma awareness and recognition can promote higher quality service delivery. Increasing stigma awareness and recognition for people with mental illness can foster confidence in overcoming psychiatric disabilities. Using a participatory action research team, our protocol included extant and newly developed stigma change tools. Organizations seeking to conduct effective evaluation studies should consider collaborative processes including the expertise of affected constituents.

The effects of news stories on the stigma of mental illness.

The media are often identified as partially responsible for increasing the stigma of mental illness through their negatively focused representations. For many years, training programs have educated journalists on how to report on mental illness to reduce stigma. This purpose of this study was to evaluate the benefits of reading a positive, neutral or a negative journalism article that discusses mental illness. Consenting adult participants were randomly assigned to read one of three published articles about recovery from mental illness, a dysfunctional public mental health system, or dental hygiene. The participants completed measures immediately before and after the intervention; the measures administered evaluated stigmatizing and affirming attitudes toward people with mental illness. Public stigma was assessed using the nine-item Attribution Questionnaire and the Stigma Through Knowledge Test (STKT). The STKT is a measure of mental illness stigma less susceptible to the impact of social desirability. Affirming attitudes represent public perceptions about recovery, empowerment, and self-determination, indicated as important to accepting and including people with psychiatric disabilities into society. Significant differences were observed between the articles on recovery and dysfunctional public mental health system, as well as the control condition, on the measures of stigma and affirming attitudes. The recovery article reduced stigma and increased affirming attitudes, whereas the dysfunctional public mental health system article increased stigma and decreased affirming attitudes. Not all journalistic stories have positive effects on attitudes about mental illness.

Measuring mental illness stigma with diminished social desirability effects.

BACKGROUND: For persons with mental illness, stigma diminishes employment and independent living opportunities as well as participation in psychiatric care. Public stigma interventions have sought to ameliorate these consequences. AIMS: Evaluation of anti-stigma programs' impact is typically accomplished with self-report questionnaires. However, cultural mores encourage endorsement of answers that are socially preferred rather than one's true belief. This problem, social desirability, has been circumvented through development of faux knowledge tests (KTs) (i.e., Error-Choice Tests); written to assess prejudice. METHOD: Our KT uses error-choice test methodology to assess stigmatizing attitudes. Test content was derived from review of typical KTs for façade reinforcement. Answer endorsement suggests bias or stigma; such determinations were based on the empirical literature. RESULTS: KT psychometrics were examined in samples of college students, community members and mental health providers and consumers. Test-retest reliability ranged from fair (0.50) to good (0.70). Construct validity analyses of public stigma indicated a positive relationship with the Attribution Questionnaire and inverse relationships with Self-Determination and Empowerment Scales. No significant relationships were observed with self-stigma measures (recovery, empowerment). CONCLUSIONS: This psychometric evaluation study suggests that a self-administered questionnaire may circumvent social desirability and have merit as a stigma measurement tool.

Self-stigma, group identification, perceived legitimacy of discrimination and mental health service use.

Stigma may interfere with mental health service use. We measured self-stigma and stigma-related cognitions (group identification and perceived legitimacy of discrimination) at baseline in 85 people with schizophrenia, schizoaffective or affective disorders. After 6 months, 75 (88%) had reported use of mental health services. Controlling for baseline psychopathology, perceived stigma and diagnosis, low perceived legitimacy of discrimination predicted use of counselling/psychotherapy. Strong group identification was associated with participation in mutual-help groups. More self-stigma predicted psychiatric hospitalisation. Cognitive indicators of stigma resilience may predict out-patient service use, whereas self-stigma may increase the risk of psychiatric hospitalisation.

A stress-coping model of mental illness stigma: I. Predictors of cognitive stress appraisal.

Stigma can be a major stressor for individuals with schizophrenia and other mental illnesses. It is unclear, however, why some stigmatized individuals appraise stigma as more stressful, while others feel they can cope with the potential harm posed by public prejudice. We tested the hypothesis that the level of perceived public stigma and personal factors such as rejection sensitivity, perceived legitimacy of discrimination and ingroup perceptions (group value; group identification; entitativity, or the perception of the ingroup of people with mental illness as a coherent unit) predict the cognitive appraisal of stigma as a stressor. Stigma stress appraisal refers to perceived stigma-related harm exceeding perceived coping resources. Stress appraisal, stress predictors and social cue recognition were assessed in 85 people with schizophrenia, schizoaffective or affective disorders. Stress appraisal did not differ between diagnostic subgroups, but was positively correlated with rejection sensitivity. Higher levels of perceived societal stigma and holding the group of people with mental illness in low regard (low group value) independently predicted high stigma stress appraisal. These predictors remained significant after controlling for social cognitive deficits, depressive symptoms and diagnosis. Our findings support the model that public and personal factors predict stigma stress appraisal among people with mental illness, independent of diagnosis and clinical symptoms. Interventions that aim to reduce the impact of stigma on people with mental illness could focus on variables such as rejection sensitivity, a personal vulnerability factor, low group value and the cognitive appraisal of stigma as a stressor.

Challenging the Stigma of Mental Illness Among College Students.

PURPOSE: This study investigated the impact of contact- and education-based antistigma interventions on mental illness stigma, affirming attitudes, discrimination, and treatment seeking among college students. METHODS: Data were collected from 198 students of a Chicago University campus in spring of 2014. Participants were randomly assigned to one of three conditions: a contact-based antistigma presentation, education-based presentation, or control condition. Measures of stigma, discrimination, affirming attitudes, and treatment seeking were administered at preintervention and postintervention. RESULTS: A 3 × 2 analysis of variance was completed for each measure to examine condition by trial interactions. Both contact- and education-based interventions demonstrated a significant impact on personal stigma, perceptions of empowerment, discrimination, attitudes towards treatment seeking, and intentions to seek treatment from formal sources. No difference in effect was demonstrated between the contact- and education-based conditions. CONCLUSIONS: These findings suggest that these two approaches should be considered for challenging mental illness stigma among college students.

Do the effects of antistigma programs persist over time? Findings from a meta-analysis.

OBJECTIVES: A previous analysis showed the positive impact of education and contact with persons with lived experience on public stigma toward mental illness, with contact yielding significantly greater effect sizes than education. This study reported a further analysis of those data that examined effects of education and contact at follow-up. METHODS: The literature (before October 2010) was searched and coded for studies that examined strategies for changing public stigma. RESULTS: The search found 72 articles, and 19 contained follow-up data. The effect size for overall impact was significantly different from zero for education, but a similar effect size was not significantly different from zero for contact because a small number of contact-intervention studies included follow-up. Effect sizes for attitudinal change were significantly different from zero for education and contact, but the effect size for contact was significantly greater. CONCLUSIONS: Future research designs need to include strategies for follow-up assessments.

Diminishing the self-stigma of mental illness by coming out proud.

This randomized controlled trial examined the impact of the Coming Out Proud (COP) program on self-stigma, stigma stress, and depression. Research participants who experienced mental health challenges were randomly assigned to a three session COP program (n=51) or a waitlist control (n=75). Outcome measures that assessed the progressively harmful stages of self-stigma, stigma stress appraisals, and depression were administered at pre-test, post-test, and one-month follow-up. People completing COP showed significant improvement at post-test and follow-up in the more harmful aspects of self-stigma compared to the control group. COP participants also showed improvements in stigma stress appraisals. Women participating in COP showed significant post-test and follow-up reductions in depression after COP compared to the control group. Men did not show this effect. Future research should determine whether these benefits also enhance attitudes related to recovery, empowerment, and self-determination.

Changing heat-related mortality in the United States.

Heat is the primary weather-related cause of death in the United States. Increasing heat and humidity, at least partially related to anthropogenic climate change, suggest that a long-term increase in heat-related mortality could occur. We calculated the annual excess mortality on days when apparent temperatures--an index that combines air temperature and humidity--exceeded a threshold value for 28 major metropolitan areas in the United States from 1964 through 1998. Heat-related mortality rates declined significantly over time in 19 of the 28 cities. For the 28-city average, there were 41.0 +/- 4.8 (mean +/- SE) excess heat-related deaths per year (per standard million) in the 1960s and 1970s, 17.3 +/- 2.7 in the 1980s, and 10.5 +/- 2.0 in the 1990s. In the 1960s and 1970s, almost all study cities exhibited mortality significantly above normal on days with high apparent temperatures. During the 1980s, many cities, particularly those in the typically hot and humid southern United States, experienced no excess mortality. In the 1990s, this effect spread northward across interior cities. This systematic desensitization of the metropolitan populace to high heat and humidity over time can be attributed to a suite of technologic, infrastructural, and biophysical adaptations, including increased availability of air conditioning.

Peer navigators and integrated care to address ethnic health disparities of people with serious mental illness.

People of color with serious mental illnesses experience high rates of morbidity and mortality. Patient navigators, developed for cancer care, may help this group benefit from integrated care. This review examined patient navigators' key ingredients for cancer care for relevance to patients of color for application of peer services to psychiatric goals. Among cancer patients, navigators lead to greater treatment engagement and improved health outcomes for ethnic minority groups. Research also suggests peers can improve integrated care by providing effective psychiatric services to individuals with mental illness. Ongoing research examines peer navigators' impact on integrated care for patients of color.

Brief battery for measurement of stigmatizing versus affirming attitudes about mental illness.

Decreasing the stigma of mental illness is not sufficient. Rather promoting important ideas, such as recovery, empowerment, and self-determination, is important to increase social inclusion, or more broadly, affirming attitudes. The goal of this article is to evaluate the psychometrics of a battery of measures that assess both stigmatizing and affirming attitudes toward people with mental illnesses. The aforementioned battery was used in four separate RCTs on stigma change with different samples: college students, adults, health care providers, and mental health service providers. Test-retest indices were satisfactory for all samples except for the Empowerment Scale score for the mental health providers. Attribution Questionnaire-9 (AQ-9) scores were significantly and inversely associated with the three affirming attitude scale scores for eight of twelve correlations, with five of these meeting the Bonferroni Criterion. Research on social attitudes and structures needs to incorporate assessment of affirming perspectives about a group and effective anti-stigma programs need to promote social inclusion and affirming attitudes.

Key ingredients to contact-based stigma change: a cross-validation.

OBJECTIVE: Contact-based antistigma programs seemingly have a larger and more sustained impact than educational strategies. Previous qualitative research of advocates with lived experiences yielded 32 key ingredients of contact-based programs comprising 5 categories. This study sought an independent sample's feedback of the 32 ingredients. METHODS: One hundred advocates with lived experience of mental health conditions who have led, coordinated, and/or delivered antistigma presentations completed an online survey to rank importance of key ingredients. RESULTS: Analysis of rank distributions showed most important ingredients in program categories: (a) design: face-to-face presentations, audience discussion; (b) target: specific group identified (e.g., employers), assessment completed with targets to derive stigma change goals relevant to needs; (c) staff: presenters are people with lived experience; (d) message: message includes on the-way-up stories; and (e) evaluation/follow-up: post-presentation follow-up actions discussed with targets. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Future research hopes to yield a fidelity measure for contact-based programs.

The California schedule of key ingredients for contact-based antistigma programs.

OBJECTIVE: A major public health priority has been to eliminate stigma's egregious effects on life opportunities for people with mental illnesses. Research shows contact-based antistigma programs are among the most effective. Such findings call for clarity to define the components of consumer-directed antistigma programs. This article represents community-based participatory research (CBPR) and the first step of a mixed methods design to describe the active ingredients comprising these kinds of programs. METHOD: CBPR investigators developed an interview guide and subsequently facilitated four focus groups to identify key components. Participants included antistigma experts with lived experience. Using grounded theory, two independent raters identified 641 discrete themes. Two additional coders then sorted themes into constructs representing key ingredients of contact-based programs. Coders agreed upon 198 constructs and then grouped them into a hierarchical model of key ingredients in consumer-directed stigma change. RESULTS: Five criteria represent indicators of successful consumer-directed programs: (a) program design-factors necessary for trained presenters to facilitate programs; (b) targeting-tailored presentation congruent with target's goal; (c) staffing-facilitators and leadership are diverse people with lived experience; (d) messaging-presentation discusses struggles and recovery from mental health challenges; and (e) follow-up and evaluation-assessment of sustained audience change. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: This study identified key ingredients of consumer-directed antistigma programs. Part two of the mixed methods design, a quantitative cross-validation study, will yield a sound fidelity measure.

Challenging the public stigma of mental illness: a meta-analysis of outcome studies.

OBJECTIVE: Public stigma and discrimination have pernicious effects on the lives of people with serious mental illnesses. Given a plethora of research on changing the stigma of mental illness, this article reports on a meta-analysis that examined the effects of antistigma approaches that included protest or social activism, education of the public, and contact with persons with mental illness. METHODS: The investigators heeded published guidelines for systematic literature reviews in health care. This comprehensive and systematic review included articles in languages other than English, dissertations, and population studies. The search included all articles from the inception of the databases until October 2010. Search terms fell into three categories: stigma, mental illness (such as schizophrenia and depression), and change program (including contact and education). The search yielded 72 articles and reports meeting the inclusion criteria of relevance to changing public stigma and sufficient data and statistics to complete analyses. Studies represented 38,364 research participants from 14 countries. Effect sizes were computed for all studies and for each treatment condition within studies. Comparisons between effect sizes were conducted with a weighted one-way analysis of variance. RESULTS: Overall, both education and contact had positive effects on reducing stigma for adults and adolescents with a mental illness. However, contact was better than education at reducing stigma for adults. For adolescents, the opposite pattern was found: education was more effective. Overall, face-to-face contact was more effective than contact by video. CONCLUSIONS: Future research is needed to identify moderators of the effects of both education and contact.

Self-stigma of mental illness scale--short form: reliability and validity.

The internalization of public stigma by persons with serious mental illnesses may lead to self-stigma, which harms self-esteem, self-efficacy, and empowerment. Previous research has evaluated a hierarchical model that distinguishes among stereotype awareness, agreement, application to self, and harm to self with the 40-item Self-Stigma of Mental Illness Scale (SSMIS). This study addressed SSMIS critiques (too long, contains offensive items that discourages test completion) by strategically omitting half of the original scale's items. Here we report reliability and validity of the 20-item short form (SSMIS-SF) based on data from three previous studies. Retained items were rated less offensive by a sample of consumers. Results indicated adequate internal consistencies for each subscale. Repeated measures ANOVAs showed subscale means progressively diminished from awareness to harm. In support of its validity, the harm subscale was found to be inversely and significantly related to self-esteem, self-efficacy, empowerment, and hope. After controlling for level of depression, these relationships remained significant with the exception of the relation between empowerment and harm SSMIS-SF subscale. Future research with the SSMIS-SF should evaluate its sensitivity to change and its stability through test-rest reliability.

SELF-STIGMA AND COMING OUT ABOUT ONE'S MENTAL ILLNESS.

Self-stigma can undermine self-esteem and self-efficacy of people with serious mental illness. Coming out may be one way of handling self-stigma and it was expected that coming out would mediate the effects of self-stigma on quality of life. This study compares coming out to other approaches of controlling self-stigma. Eighty-five people with serious mental illness completed measures of coming out (called the Coming Out with Mental Illness Scale, COMIS), self-stigma, quality of life, and strategies for managing self-stigma. An exploratory factor analysis of the COMIS uncovered two constructs: benefits of being out (BBO) and reasons for staying in. A mediational analysis showed BBO diminished self-stigma effects on quality of life. A factor analysis of measures of managing self-stigma yielded three factors. Benefits of being out was associated with two of these: affirming strategies and becoming aloof, not with strategies of shame. Implications for how coming out enhances the person's quality of life are discussed.