The effects of different types of organisational workplace mental health interventions on mental health and wellbeing in healthcare workers: a systematic review.

OBJECTIVE: To determine if and which types of organisational interventions conducted in small and medium size enterprises (SMEs) in healthcare are effective on mental health and wellbeing. METHODS: Following PRISMA guidelines, we searched six scientific databases, assessed the methodological quality of eligible studies using QATQS and grouped them into six organisational intervention types for narrative synthesis. Only controlled studies with at least one follow-up were eligible. RESULTS: We identified 22 studies (23 articles) mainly conducted in hospitals with 16 studies rated of strong or moderate methodological quality. More than two thirds (68%) of the studies reported improvements in at least one primary outcome (mental wellbeing, burnout, stress, symptoms of depression or anxiety), most consistently in burnout with eleven out of thirteen studies. We found a strong level of evidence for the intervention type "Job and task modifications" and a moderate level of evidence for the types "Flexible work and scheduling" and "Changes in the physical work environment". For all other types, the level of evidence was insufficient. We found no studies conducted with an independent SME, however five studies with SMEs attached to a larger organisational structure. The effectiveness of workplace mental health interventions in these SMEs was mixed. CONCLUSION: Organisational interventions in healthcare workers can be effective in improving mental health, especially in reducing burnout. Intervention types where the change in the work environment constitutes the intervention had the highest level of evidence. More research is needed for SMEs and for healthcare workers other than hospital-based physicians and nurses.

Finding the right words: Articulating the value of mental health promotion. A focus group study.

The Lapinlahti Hospital initiative in Helsinki has transformed a disused psychiatric hospital into an open site for mental health promotion. The current study uses qualitative methods to explore how the initiative may promote population mental health. The phenomenological study comprised of data from 7 focus group including 28 participants. Resulting data were thematically analysed to articulate how the initiative supports mental wellbeing in different ways. Mental health benefits were categorized into three themes; mental health value, civil values and common values which were comprised of nine subthemes; paradigm shift, social inclusion, personal meaning, regeneration, ambience, stigma, sustainability, democracy and environment. Mental health promotion emphasises the impact of daily environments in which people live their lives. Results from this study support the use of broad based actions which promote different components of mental wellbeing simultaneously. Psychiatric hospitals may offer historically meaningful sites for such actions.

'If we would change things outside we wouldn't even need to go in ' supporting recovery via community-based actions: A focus group study on psychiatric rehospitalization.

BACKGROUND: Psychiatric rehospitalization is a complex phenomenon in need of more person-centred approaches. The current paper aimed to explore how community-based actions and daily life influence mental health and rehospitalization. DESIGN, SETTING AND PARTICIPANTS: The qualitative study included focus group data from six European countries including 59 participants. Data were thematically analysed following an inductive approach deriving themes and subthemes in relation to facilitators and barriers to mental health. RESULTS: Barriers consisted of subthemes (financial difficulty, challenging family circumstances and stigma), and facilitators consisted of three subthemes (complementing services, signposting and recovery). The recovery subtheme consisted of a further five categories (family and friends, work and recreation, hope, using mental health experience and meaning). DISCUSSION: Barriers to mental health largely related to social determinants of mental health, which may also have implications for psychiatric rehospitalization. Facilitators included community-based actions and aspects of daily life with ties to personal recovery. By articulating the value of these facilitators, we highlight benefits of a person-centred and recovery-focused approach also within the context of psychiatric rehospitalization. CONCLUSIONS: This paper portrays how person-centred approaches and day-to-day community actions may impact psychiatric rehospitalization via barriers and facilitators, acknowledging the social determinants of mental health and personal recovery. PATIENT OR PUBLIC CONTRIBUTION: The current study included participants with experience of psychiatric rehospitalization from six different European countries. Furthermore, transcripts were read by several of the focus group participants, and a service user representative participated in the entire research process in the original study.

Instruments to evaluate mental well-being in old age: a systematic review.

OBJECTIVE: The aim of this study is to identify and appraise existing instruments to evaluate mental well-being in old age. METHOD: Systematic literature searches in PubMed, PsycINFO, ProQuest Research Library, AgeLine and CINAHL databases were performed. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline was used to assess the measurement properties, reported according to the Preferred Reporting Items for Systematic Reviews and meta-Analysis (PRISMA) statement. For each measurement property, results were classified as positive, negative or indeterminate. The quality level of evidence was rated as high, moderate, low or very low following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS: A total of 28 instruments were found. Most instruments evaluated different dimensions of mental well-being, including various subscales. The quality was adequate overall. Six instruments showed high quality (Perceived Well-Being Scale-PWB, Salamon-Conte Life Satisfaction in the Elderly Scale-SCLSES, Herth Hope Scale-HHS, Life Satisfaction Index Third Age-LSITA, Meaning in Life Scale-MLS, and SODdisfazione dell'Anziano-SODA), and other six a moderate level (Scale of Happiness of the Memorial University of Newfoundland-MUNSH, Six Scales of Psychological Well-Being-PWBS, Valuation Of Life-VOL, Life Satisfaction Scale for Chinese Elders-LSS-C, Meaningful Activity Participation Assessment-MAPA and Will To Life-WTL). CONCLUSION: This review provides the first comprehensive synthesis of instruments assessing mental well-being in older populations. The PWB, SCLSES, HHS, LSITA, MLS and SODA were the most appropriated instruments. An instrument that specifically measures mental well-being in the oldest old age group (aged 80 plus) and that considers its multidimensional nature is needed.

The Economic Case for the Prevention of Mental Illness.

Poor mental health has profound economic consequences. Given the burden of poor mental health, the economic case for preventing mental illness and promoting better mental health may be very strong, but too often prevention attracts little attention and few resources. This article describes the potential role that can be played by economic evidence alongside experimental trials and observational studies, or through modeling, to substantiate the need for increased investment in prevention. It illustrates areas of action across the life course where there is already a good economic case. It also suggests some further areas of substantive public health concern, with promising effectiveness evidence, that may benefit from economic analysis. Financial and economic barriers to implementation are then presented, and strategies to address the barriers and increase investment in the prevention of mental illness are suggested.

Morbidity and housing status 10 years after shelter use-follow-up of homeless men in Helsinki, Finland.

Background: Homelessness is associated with increased mortality, morbidity and social difficulties and periods of homelessness are sometimes prolonged or repeated. However, there are no long-term follow-up studies focusing upon housing status among homeless people. The aim of this study was to examine morbidity and housing outcomes and to identify factors predicting being independently housed 10 years after shelter use. Methods: By combining data from several registers we followed all 552 homeless men who stayed in shelter in Helsinki during 2004 and determined their housing situation and morbidity 10 years later. Their situation was compared with an age-matched control group from the general population (N = 946). Using logistic regression analysis, we assessed the predictive effects of socioeconomic factors and health service use at baseline on becoming independently housed. Results: By the end of the follow-up 52.0% of the formerly homeless study group had died, compared with 14.6% of the controls. At 10 years, 6.0% were independently housed, 37.5% lived in supported housing and 4.5% were still or again homeless. Psychiatric disorders, including substance use disorder, were present in 77.5% of the homeless, compared with 16.1% among the controls. Being married (OR 8.3, 95% CI 3.0 to 23.2) and having less than four shelter nights in year 2004 (OR 9.1, 95% CI 2.7 to 30.8) strongly predicted being independently housed 10 years later. Conclusions: Homeless staying in shelters have high mortality and morbidity and most of those surviving, are in need of support in their everyday lives even years after the shelter period.

Promoting mental wellbeing among older people: technology-based interventions.

This systematic review explored the effectiveness of technology-based interventions in promoting the mental health and wellbeing of people aged 65 and over. Data were collected as part of a wider review commissioned by the National Institute for Health and Care Excellence (NICE) in England on the effectiveness of different actions to promote the mental wellbeing and independence of older people. All studies identified through this review were subject to a detailed critical appraisal of quality, looking at internal and external validity. Twenty-one papers covering evaluations of technological interventions were identified. They examined the psychosocial effects of technologies for education, exposure to, and/or training to use, computers and the internet, telephone/internet communication and computer gaming. Few studies took the form of randomized controlled trials, with little comparability in outcome measures, resulting in an inconsistent evidence base with moderate strength and quality. However, three out of six studies with high or moderate quality ratings (all focused on computer/internet training) reported statistically significant positive effects on psychosocial outcomes, including increased life satisfaction and experienced social support, as well as reduced depression levels among intervention recipients. The review results highlight the need for more methodologically rigorous studies evaluating the effects of technology-based interventions on mental wellbeing. Well-performed technology-based interventions to promote various aspects of mental wellbeing, as identified in this review, can serve as best practice examples in this emerging field.

Psychiatric readmissions and their association with physical comorbidity: a systematic literature review.

BACKGROUND: Comorbidity between mental and physical disorder conditions is the rule rather than the exception. It is estimated that 25% of adult population have mental health condition and 68% of them suffer from comorbid medical condition. Readmission rates in psychiatric patients are high and we still lack understanding potential predictors of recidivism. Physical comorbidity could be one of important risk factors for psychiatric readmission. The aim of the present study was to review the impact of physical comorbidity variables on readmission after discharge from psychiatric or general inpatient care among patients with co-occurring psychiatric and medical conditions. METHODS: A comprehensive database search from January 1990 to June 2014 was performed in the following bibliographic databases: Ovid Medline, PsycINFO, ProQuest Health Management, OpenGrey and Google Scholar. An integrative research review was conducted on 23 observational studies. RESULTS: Six studies documented physical comorbidity variables only at admission/discharge and 17 also at readmission. The main body of studies supported the hypothesis that patients with mental disorders are at increased risk of readmission if they had co-occurring medical condition. The impact of physical comorbidity variables on psychiatric readmission was most frequently studied in in patients with affective and substance use disorders (SUD). Most common physical comorbidity variables with higher probability for psychiatric readmission were associated with certain category of psychiatric diagnoses. Chronic lung conditions, hepatitis C virus infection, hypertension and number of medical diagnoses were associated with increased risk of readmission in SUD; Charlson Comorbidity Index, somatic complaints, physical health problems with serious mental illnesses (schizophrenia, schizoaffective disorder, personality disorders); not specified medical illness, somatic complaints, number of medical diagnoses, hyperthyroidism with affective disorders (depression, bipolar disorder). Co-occurring physical and mental disorders can worsen patient's course of illness leading to hospital readmission also due to non-psychiatric reasons. CONCLUSIONS: The association between physical comorbidity and psychiatric readmission is still poorly understood phenomenon. Nevertheless, that physical comorbid conditions are more common among readmitted patients than single admission patients, their association with readmission can vary according to the nature of mental disorders, characteristics of study population, applied concept of comorbidity, and study protocol.

Interventions to mitigate the effects of poverty and inequality on mental health.

PURPOSE: To review psychosocial and policy interventions which mitigate the effects of poverty and inequality on mental health. METHODS: Systematic reviews, controlled trials and realist evaluations of the last 10 years are reviewed, without age or geographical restrictions. RESULTS: Effective psychosocial interventions on individual and family level, such as parenting support programmes, exist. The evidence for mental health impact of broader community-based interventions, e.g. community outreach workers, or service-based interventions, e.g. social prescribing and debt advice is scarce. Likewise, the availability of evidence for the mental health impact of policy level interventions, such as poverty alleviation or youth guarantee, is quite restricted. CONCLUSIONS: The social, economic, and physical environments in which people live shape mental health and many common mental disorders. There are effective early interventions to promote mental health in vulnerable groups, but it is necessary to both initiate and facilitate a cross-sectoral approach, and to form partnerships between different government departments, civic society organisations and other stakeholders. This approach is referred to as Mental Health in All Policies and it can be applied to all public policy levels from local policies to supranational.

Mental disorders and the use of primary health care services among homeless shelter users in the Helsinki metropolitan area, Finland.

BACKGROUND: Homelessness is associated with increased morbidity, mortality and health care use. The aim of this study was to examine the role of mental disorders in relation to the use of 1) daytime primary health care services and 2) after hours primary health care emergency room (PHER) services among homeless shelter users in the Helsinki Metropolitan Area, Finland. METHODS: The study cohort consists of all 158 homeless persons using the four shelters operating in the study area during two selected nights. The health records were analyzed over a period of 3 years prior to the sample nights and data on morbidity and primary health care visits were gathered. We used negative binomial regression to estimate the association between mental disorders and daytime visits to primary health care and after hours visits to PHERs. RESULTS: During the 3 years the 158 homeless persons in the cohort made 1410 visits to a physician in primary health care. The cohort exhibited high rates of mental disorders, including substance use disorders (SUDs); i.e. 141 persons (89%) had a mental disorder. We found dual diagnosis, defined as SUD concurring with other mental disorder, to be strongly associated with daytime primary health care utilization (IRR 11.0, 95% CI 5.9-20.6) when compared with those without any mental disorder diagnosis. The association was somewhat weaker for those with only SUDs (IRR 4.9, 95% CI 2.5-9.9) or with only other mental disorders (IRR 5.0, 95% CI 2.4-10.8). When focusing upon the after hours visits to PHERs we observed that both dual diagnosis (IRR 14.1, 95% CI 6.3-31.2) and SUDs (11.5, 95% CI 5.7-23.3) were strongly associated with utilization of PHERs compared to those without any mental disorder. In spite of a high numbers of visits, we found undertreatment of chronic conditions such as hypertension and diabetes. CONCLUSIONS: Dual diagnosis is particularly strongly associated with primary health care daytime visits among homeless persons staying in shelters, while after hours visits to primary health care level emergency rooms are strongly associated with both dual diagnosis and SUDs. Active treatment for SUDs could reduce the amount of emergency visits made by homeless shelter users.

Promotion of mental health in the core of public health work.

Positive trends achieved in health in Finland are not equally reflected mental health, hence mental health promotion deserves a central position. Mental health promotion refers to strengthening of psychological resources, and has been linked to increased well-being and life satisfaction. Health care has an important role in supporting a solid foundation of mental health and in preventing intergenerational transmission of problems. Mental health promotion requires strong involvement of non-health sectors. There are means for strengthening mental health skills also on the individual level. The gap between existing evidence on effectiveness and cost-effectiveness of mental health promotion and the lack of large scale implementation needs to addressed by future health and social policies.

Psychiatric readmissions and their association with environmental and health system characteristics: a systematic review of the literature.

BACKGROUND: Psychiatric readmissions have been studied at length. However, knowledge about how environmental and health system characteristics affect readmission rates is scarce. This paper systemically reviews and discusses the impact of health and social systems as well as environmental characteristics for readmission after discharge from inpatient care for patients with a psychiatric diagnosis. METHODS: Comprehensive literature searches were conducted in the electronic bibliographic databases Ovid Medline, PsycINFO, ProQuest Health Management and OpenGrey. In addition, Google Scholar was utilised. Relevant publications published between January 1990 and June 2014 were included. No restrictions regarding language or publication status were imposed. A qualitative synthesis of the included studies was performed. Variables describing system and environmental characteristics were grouped into three groups: those capturing regulation, financing system and governance; those capturing capacity, organisation and structure; and those capturing environmental variables. RESULTS: Of the 734 unique articles identified in the original search, 35 were included in the study. There is a limited number of studies on psychiatric readmissions and their association with environmental and health system characteristics. Even though the review reveals an extensive list of characteristics studied, most characteristics appear in a very limited number of articles. The most frequently studied characteristics are related to location (local area, district/region/country). In most cases area differences were found, providing strong indication that the risk of readmission not only relates to patient characteristics but also to system and/or environmental factors that vary between areas. The literature also points in the direction of a negative association of institutional length of stay and community aftercare with readmission for psychiatric patients. CONCLUSION: This review shows that analyses of system level variables are scarce. Furthermore they differ with respect to purpose, choice of system characteristics and the way these characteristics are measured. The lack of studies looking at the relationship between readmissions and provider payment models is striking. Without the link to provider payment models and other health system characteristics related to regulation, financing system and governance structure it becomes more difficult to draw policy implications from these analyses.

Statistical methods and modelling techniques for analysing hospital readmission of discharged psychiatric patients: a systematic literature review.

BACKGROUND: Psychiatric services have undergone profound changes over the last decades. CEPHOS-LINK is an EU-funded study project with the aim to compare readmission of patients discharged with psychiatric diagnoses using a registry-based observational record linkage study design and to analyse differences in the findings for five different countries. A range of different approaches is available for analysis of the available data. Although there are some studies that compare selected methods for evaluating questions on readmission, there are to our knowledge no published systematic literature reviews on commonly used methods and their comparison. This work shall therefore provide an overview of the methods in use, their evolution throughout history and new developments which can further improve the research quality in this area. METHODS: Based on systematic literature reviews realized in the course of the CEPHOS-LINK study, this work is a systematic evaluation of mathematical (statistical and modelling) methods used in studies examining psychiatric readmission. The starting point were 502 papers, of which 407 were analysed in detail; Methods used were assigned to one of five categories with subcategories and analysed accordingly. Our particular interest next to survival analysis and regression models is modelling and simulation. RESULTS: As population sizes and follow-up times in the included studies varied widely, a range of methods was applied. Studies with bigger sample sizes conducted survival and regression analysis more often than studies with fewer patients did. These latter relied more on classical statistical tests (e.g. t-tests and Student Newman Keuls). Statistical strategies were often insufficiently described, posing a major problem for the evaluation. Almost all cases failed to provide and explanation of the rationale behind using certain methods. CONCLUSION: There is a discernible trend from classical parametric/nonparametric tests in older studies towards regression and survival analyses in more recent ones. Modelling and simulation were under-represented despite their high usability, as has been identified in other health applications and comparable research areas.

How size matters: exploring the association between quality of mental health services and catchment area size.

BACKGROUND: The diversity of mental health and substance abuse services (MHS) available to service users is seen as an indicator of the quality of the service system. In most countries MHS are provided by a mix of public, private and third sector providers. In Finland, officially, the municipalities are responsible for organizing the services needed, but the real extent and roles of private and third sector service providers are not known. Our previous study showed that the catchment area population size was strongly associated with diversity of mental health services. It is not known whether this was due to some types of services or some provider types being more sensitive to the size effect than others. The aim of this study was to investigate the association between area population size and diversity of mental health services, i.e. which types of services and which service providers' contributions are sensitive to population size. METHODS: To map and classify services, we used the ESMS-R. The diversity of services was defined as the count of main types of care. Providers were classified as public, private or third sectors. RESULTS: The diversity of outpatient, residential and voluntary services correlated positively with catchment area population size. The strongest positive correlation between the size of population and services available was found in third sector activities followed by public providers, but no correlation was found for diversity of private services. The third sector and public corporations each provided 44 % of the service units. Third sector providers produced all self-help services and most of the day care services. Third sector and private companies provided a significant part (59 %) of the residential care service units. CONCLUSIONS: Significant positive correlations were found between size of catchment area population and diversity of residential, outpatient and voluntary services, indicating that these services concentrate on areas with larger population bases. The third sector seems to significantly complement the public sector in providing different services. Thus the third sector be needs to be functionally integrated with other MHS services to achieve a diversified and integrated service system.

Cross-national variations in reported discrimination among people treated for major depression worldwide: the ASPEN/INDIGO international study.

BACKGROUND: No study has so far explored differences in discrimination reported by people with major depressive disorder (MDD) across countries and cultures. AIMS: To (a) compare reported discrimination across different countries, and (b) explore the relative weight of individual and contextual factors in explaining levels of reported discrimination in people with MDD. METHOD: Cross-sectional multisite international survey (34 countries worldwide) of 1082 people with MDD. Experienced and anticipated discrimination were assessed by the Discrimination and Stigma Scale (DISC). Countries were classified according to their rating on the Human Development Index (HDI). Multilevel negative binomial and Poisson models were used. RESULTS: People living in 'very high HDI' countries reported higher discrimination than those in 'medium/low HDI' countries. Variation in reported discrimination across countries was only partially explained by individual-level variables. The contribution of country-level variables was significant for anticipated discrimination only. CONCLUSIONS: Contextual factors play an important role in anticipated discrimination. Country-specific interventions should be implemented to prevent discrimination towards people with MDD.

Contribution of the Nordic School of Public Health to the public mental health research field: a selection of research initiatives, 2007-2014.

The field of public mental health has been defined by an expert group convened by the Nordic School of Public Health (NHV) as encompassing the experience, occurrence, distribution and trajectories of positive mental health and mental health problems and their determinants; mental health promotion and prevention of mental disorders; as well as mental health system policies, governance and organization. The mental health priorities of the Nordic Council of Ministers in 2010 signalled a mutual Nordic exchange of knowledge in the following thematic areas: child and adolescent mental health; working life and mental health; mental health in older people; strengthening the role of primary care in mental health service provision; stronger involvement of users and carers; and reduction of use of coercion in psychiatric care. Efforts to realize these priorities included commissioning the Nordic Research Academy for Mental Health, an NHV-based network of research institutions with a common interest in mental health research across the Nordic countries, to develop, organize and follow-up projects on public mental health. The research initiatives included mental health policy analysis, register-based research and research focused on the users' perspective in a Nordic context, as well as EU-level research policy analysis. The public mental health research conducted at the NHV highlighted the complexity of mental health and emphasized that the broad determinants of mental health need to be increasingly addressed in both public health research and practice. For example, health promotion actions, improved access to health care, a healthy alcohol policy and prevention of suicides and violence are all needed to reduce the life expectancy gap - a red flag indicator of public health inequalities. By exchanging knowledge and best practice, the collaboration between the Nordic countries contributes to the welfare of the region. The expertise and traditions developed at the NHV are of significant importance in this work.

Mental health and alcohol use: a cross-sectional study of the Finnish general population.

BACKGROUND: The connections between alcohol use, mental health problems and mental well-being have been under-researched. We examined the links between different aspects of alcohol use and positive and negative aspects of mental health, and the effect of protective social factors on these links. METHODS: A cross-sectional general population survey of Finns aged 15-69 years was carried out in 2008 (n = 2725, response rate 74%). The included aspects of alcohol use were the frequency and volume of drinking, binge drinking and hazardous drinking using Alcohol Use Disorders Identification Test (AUDIT). The included aspects of mental health were subjective well-being (life satisfaction), self-efficacy (sense of mastery) and psychological distress using the General Health Questionnaire. The protective social factors examined were social support (loneliness, having a confidant) and socioeconomic status. RESULTS: Binge drinking and, particularly, hazardous drinking were associated with different aspects of mental health. The proportion of respondents with poor mental well-being increased when binge drinking was more frequent than monthly, and when respondents scored ≥6 on the AUDIT scale. Abstainers reported poor sense of mastery and former drinkers additionally reported poor satisfaction with life. Frequency and volume of drinking did not have a consistent connection with mental health. These associations between alcohol use and mental health did not depend on the protective social factors. CONCLUSIONS: Frequent binge drinking and alcohol problems are associated with poor mental health, especially with a lack of life satisfaction and psychological distress. This result applies equally to lower and higher social status groups.

Research priorities for public mental health in Europe: recommendations of the ROAMER project.

BACKGROUND: The ROAdmap for MEntal health Research in Europe project aimed to create an integrated European roadmap for mental health research. Leading mental health research experts across Europe have formulated consensus-based recommendations for future research within the public mental health field. METHODS: Experts were invited to compile and discuss research priorities in a series of topic-based scientific workshops. In addition, a Delphi process was carried out to reach consensus on the list of research priorities and their rank order. Three web-based surveys were conducted. Nearly 60 experts were involved in the priority setting process. RESULTS: Twenty priorities for public mental health research were identified through the consensus process. The research priorities were divided into summary principles-encompassing overall recommendations for future public mental health research in Europe-and thematic research priorities, including area-specific top priorities on research topics and methods. The priorities represent three overarching goals mirroring societal challenges, that is, to identify causes, risk and protective factors for mental health across the lifespan; to advance the implementation of effective public mental health interventions and to reduce disparities in mental health. CONCLUSIONS: The importance of strengthening research on the implementation and dissemination of promotion, prevention and service delivery interventions in the mental health field needs to be emphasized. The complexity of mental health and its broader conceptualisation requires complementary research approaches and interdisciplinary collaboration to better serve the needs of the European population.

[Update on Current Care Guidelines: Post-traumatic Stress Disorder]. / Kaypa Hoite-Suosituksen Paivitystiivistelma. Traumaperäinen stressihäiriö.

The updated Current Care Guidelines for ASD and PTSD recommend psychosocial support and careful monitoring for acute stress reaction (ASR) and acute stress disorder (ASD). If symptoms require, short focused cognitive-behavioral psychotherapy can be used for ASD. Medication is rarely necessary. Trauma-focused psychotherapeutic interventions are the first-line treatment for post-traumatic stress disorder (PTSD). Antidepressant medication is an effective second-line treatment. Psychotherapeutic interventions and medication should often be combined. Specific groups, such as children, the elderly, and military and peacekeeping personnel need tailored interventions.

Global pattern of experienced and anticipated discrimination reported by people with major depressive disorder: a cross-sectional survey.

BACKGROUND: Depression is the third leading contributor to the worldwide burden of disease. We assessed the nature and severity of experienced and anticipated discrimination reported by adults with major depressive disorder worldwide. Moreover, we investigated whether experienced discrimination is related to clinical history, provision of health care, and disclosure of diagnosis and whether anticipated discrimination is associated with disclosure and previous experiences of discrimination. METHODS: In a cross-sectional survey, people with a diagnosis of major depressive disorder were interviewed in 39 sites (35 countries) worldwide with the discrimination and stigma scale (version 12; DISC-12). Other inclusion criteria were ability to understand and speak the main local language and age 18 years or older. The DISC-12 subscores assessed were reported discrimination and anticipated discrimination. Multivariable regression was used to analyse the data. FINDINGS: 1082 people with depression completed the DISC-12. Of these, 855 (79%) reported experiencing discrimination in at least one life domain. 405 (37%) participants had stopped themselves from initiating a close personal relationship, 271 (25%) from applying for work, and 218 (20%) from applying for education or training. We noted that higher levels of experienced discrimination were associated with several lifetime depressive episodes (negative binomial regression coefficient 0·20 [95% CI 0·09-0·32], p=0·001); at least one lifetime psychiatric hospital admission (0·29 [0·15-0·42], p=0·001); poorer levels of social functioning (widowed, separated, or divorced 0·10 [0·01-0·19], p=0·032; unpaid employed 0·34 [0·09-0·60], p=0·007; looking for a job 0·26 [0·09-0·43], p=0·002; and unemployed 0·22 [0·03-0·41], p=0·022). Experienced discrimination was also associated with lower willingness to disclose a diagnosis of depression (mean discrimination score 4·18 [SD 3·68] for concealing depression vs 2·25 [2·65] for disclosing depression; p<0·0001). Anticipated discrimination is not necessarily associated with experienced discrimination because 147 (47%) of 316 participants who anticipated discrimination in finding or keeping a job and 160 (45%) of 353 in their intimate relationships had not experienced discrimination. INTERPRETATION: Discrimination related to depression acts as a barrier to social participation and successful vocational integration. Non-disclosure of depression is itself a further barrier to seeking help and to receiving effective treatment. This finding suggests that new and sustained approaches are needed to prevent stigmatisation of people with depression and reduce the effects of stigma when it is already established. FUNDING: European Commission, Directorate General for Health and Consumers, Public Health Executive Agency.