Help-seeking processes related to targeted school-based mental health services: systematic review.

BACKGROUND: One in seven adolescents globally are affected by mental health conditions, yet only a minority receive professional help. School-based mental health services have been endorsed as an effective way to increase access to mental health support for people at risk, or currently presenting with mental health conditions, throughout adolescence. Despite this, low treatment utilisation prevails, therefore the aim of this review is to contribute insights into the processes related to adolescents' accessing and engaging with essential targeted mental health support within schools. METHODS: This systematic review extracted qualitative, quantitative and mixed-methods data to determine what processes affect adolescents seeking help from targeted school-based mental health services (TSMS). Searches were conducted in EMBASE, Medline, PsycINFO, CINAHL, ERIC, Web of Science, in addition to manual searching and expert consultations. Data were synthesised following guidelines for thematic synthesis and narrative style synthesis. RESULTS: The search resulted in 22 articles reflecting 16 studies with participant sample sizes ranging from n = 7 to n = 122. Three main themes were identified: 'access-related factors', 'concerns related to stigma', and 'the school setting'. These findings elucidate how help-seeking processes are variable and can be facilitated or hindered depending on the circumstance. We identified disparities with certain groups, such as those from low-socio economic or ethnic minority backgrounds, facing more acute challenges in seeking help. Help-seeking behaviours were notably influenced by concerns related to peers; an influence further accentuated by minority groups given the importance of social recognition. Conflicting academic schedules significantly contribute to characterising treatment barriers. CONCLUSIONS: The findings of this review ought to guide the delivery and development of TSMS to facilitate access and promote help-seeking behaviours. Particularly, given the evidence gaps identified in the field, future studies should prioritise investigating TSMS in low- and middle-income settings and through quantitative methodologies. REGISTRATION: The protocol for this systematic review was registered on PROSPERO (ID CRD42023406824).

Effects of mental health status during adolescence on primary care costs in adulthood across three British cohorts.

PURPOSE: This study examines the association between mental health problems in adolescence and general practice (GP) costs during adulthood up to age 50 in the UK. METHODS: We conducted secondary analyses of three British birth cohorts (individuals born in single weeks in 1946, 1958 and 1970). Data for the three cohorts were analysed separately. All respondents who participated in the cohort studies were included. Adolescent mental health status was assessed in each cohort using the Rutter scale (or, for one cohort, a forerunner of that scale) completed in interviews with parents and teachers when cohort members were aged around 16. Presence and severity of conduct and emotional problems were modelled as independent variables in two-part regression models in which the dependent variable was costs of GP services from data collection sweeps up to mid-adulthood. All analyses were adjusted for covariates (cognitive ability, mother's education, housing tenure, father's social class and childhood physical disability). RESULTS: Adolescent conduct and emotional problems, particularly when coexisting, were associated with relatively high GP costs in adulthood up to age 50. Associations were generally stronger in females than males. CONCLUSION: Associations between adolescent mental health problems and annual GP cost were evident decades later, to age 50, suggesting that there could be significant future savings to healthcare budgets if rates of adolescent conduct and emotional problems could be reduced. TRIAL REGISTRATION: Not applicable.

Frontline Health Care Workers' Mental Health and Well-Being During the First Year of the COVID-19 Pandemic: Analysis of Interviews and Social Media Data.

BACKGROUND: The COVID-19 pandemic has shed light on fractures in health care systems worldwide and continues to have a significant impact, particularly in relation to the health care workforce. Frontline staff have been exposed to unprecedented strain, and delivering care during the pandemic has affected their safety, mental health, and well-being. OBJECTIVE: This study aimed to explore the experiences of health care workers (HCWs) delivering care in the United Kingdom during the COVID-19 pandemic to understand their well-being needs, experiences, and strategies used to maintain well-being (at individual and organizational levels). METHODS: We analyzed 94 telephone interviews with HCWs and 2000 tweets about HCWs' mental health during the first year of the COVID-19 pandemic. RESULTS: The results were grouped under 6 themes: redeployment, clinical work, and sense of duty; well-being support and HCW's coping strategies; negative mental health effects; organizational support; social network and support; and public and government support. CONCLUSIONS: These findings demonstrate the need for open conversations, where staff's well-being needs and the strategies they adopted can be shared and encouraged, rather than implementing top-down psychological interventions alone. At the macro level, the findings also highlighted the impact on HCW's well-being of public and government support as well as the need to ensure protection through personal protective equipment, testing, and vaccines for frontline workers.

Influence of stigma, sociodemographic and clinical characteristics on mental health-related service use and associated costs among young people in the United Kingdom.

This study examined the influence of stigma, psychopathology, and sociodemographic characteristics on mental health-related service use and costs related to service use in a cohort of young people in the UK. Using data from a community sample of young people aged 9-17 years and their caregivers, we assessed 407 young people's use of services due to mental health problems, young people's psychopathology, demographic characteristics, maternal education and caregivers' stigma-related beliefs. Unit costs related to services were gathered from national annual compendia and other widely used sources. We assessed predictors of service use through logistic regression analysis and developed generalised linear models to identify factors associated with costs of mental health-related service utilisation. Persistent psychopathology, socioeconomic disadvantage, and low caregiver intended stigma-related behaviour were associated with increased likelihood of service use among young people. Older age and socioeconomic disadvantage were associated with increased costs. Different factors influenced contact with services and the cost associated with their use - persistent psychopathology and socioeconomic disadvantage increased, and caregivers' intended stigma-related behaviour decreased the likelihood of using services, whereas socioeconomic disadvantage and older age were associated with increased costs. Social determinants of mental health problems play an important role in the use and costs of different types of mental health-related services for young people. Discordance between drivers of service use and costs implies that young people who are more likely to access services due to mental health problems do not necessarily receive care at the intensity they need.

Gaps and challenges: WHO treatment recommendations for tobacco cessation and management of substance use disorders in people with severe mental illness.

BACKGROUND: People with severe mental disorders (SMD) experience premature mortality mostly from preventable physical causes. The World Health Organization (WHO) have recently produced guidelines on the management of physical health conditions in SMD. This paper presents the evidence which led to the recommendations for tobacco cessation and management of substance use disorders in SMD. METHODS: Scoping reviews informed 2 PICO (Population Intervention, Comparator, Outcome) questions relating to tobacco cessation and management of substance use disorders in SMD. Systematic searches led to the identification of systematic reviews with relevant evidence to address these questions. Retrieved evidence was assessed using GRADE methodology, informing the development of guidelines. RESULTS: One thousand four hundred thirty-four records were identified through systematic searches for SMD and tobacco cessation, of which 4 reviews were included in GRADE tables and 18 reviews in narrative synthesis. For SMD and substance use disorders, 4268 records were identified, of which 4 studies from reviews were included in GRADE tables and 16 studies in narrative synthesis. People with SMD who use tobacco should be offered combined pharmacological (Varenicline, Bupropion or Nicotine Replacement Therapy) and non-pharmacological interventions such as tailored directive and supportive behavioural interventions. For people with SMD and substance use disorders (drug and/or alcohol), interventions should be considered in accordance with WHO mhGAP guidelines. Prescribers should note potential drug-drug interactions. Recommendation were conditional and based on low/very low certainty of evidence with a scarcity of evidence from low- and middle-income settings. CONCLUSIONS: These guidelines mark an important step towards addressing premature mortality in people with SMD. The dearth of high-quality evidence and evidence from LMIC settings must inform the future research agenda. GUIDELINES: https://www.who.int/mental_health/evidence/guidelines_physical_health_and_severe_mental_disorders/en https://www.who.int/publications-detail/mhgap-intervention-guide%2D%2D-version-2.0.

Correction to: Gaps and challenges: WHO treatment recommendations for tobacco cessation and management of substance use disorders in people with severe mental illness.

An amendment to this paper has been published and can be accessed via the original article.

Childhood bullying victimization, self-labelling, and help-seeking for mental health problems.

PURPOSE: Previous research found sustained high levels of mental health service use among adults who experienced bullying victimization during childhood. This could be due to increased psychopathology among this group, but other factors, such as self-perception as having a mental health problem, might contribute to increased service use. Additionally, the relationship between informal help-seeking for mental health problems and bullying victimization is incompletely understood. METHODS: The present study examined associations between the frequency of bullying victimization and both formal service use and informal help-seeking for mental health problems independent from psychopathology. Data on bullying victimization, service use, informal help-seeking for mental health problems, psychopathology, and self-labelling as a person with mental illness were collected among 422 young people aged 13-22 years. RESULTS: In logistic regression models, controlling for past and current psychopathology and using no bullying victimization as the reference category, we identified a greater likelihood of mental health service use among persons who experienced frequent bullying victimization, as well as a greater likelihood of seeking informal help among persons who experienced occasional victimization. Increased self-identification as a person with mental illness completely mediated the positive association between frequent bullying victimization and mental health service use. CONCLUSIONS: Our findings suggest that services to support persons who experienced frequent bullying victimization should focus on improving empowerment and self-perception. Additionally, there might be unserved need for formal support among those who experienced occasional bullying victimization.

Psychometric validation of the self-identification of having a mental illness (SELF-I) scale and the relationship with stigma and help-seeking among young people.

PURPOSE: Self-identification of having a mental illness has been shown to be an important factor underpinning help-seeking behaviour and may mediate the relationship between personal stigma and mental health service use. This study validates a new scale for the self-identification of having a mental illness among a non-clinical, community cohort of young people in the UK. METHODS: Following consultation with a group of young person experts with experience of mental health problems, we evaluated the psychometric properties of the self-identification of mental illness scale (SELF-I) among 423 young people aged 13-24 years who are part of an ongoing prospective community cohort. We performed test retest reliability among a subset of 53 participants. Psychometric validation for the scale used measures of Cronbach's alpha and Pearson's correlation coefficient. Item performance was assessed along and in relation with each covariate. RESULTS: The SELF-I demonstrated robust psychometric properties including high test-retest reliability (0.95) and good internal consistency (0.87 as determined by the Cronbach's alpha). The inter-total correlations for each item, which ranged from 0.62 to 0.74, supported keeping all items in the scale. Reporting greater psychiatric symptomatology via the SDQ (ß: 0.82 95% confidence interval 0.40, 1.23), psychotic-like experiences (ß: 0.37 95% confidence interval 0.14, 0.59), and use of mental health services (ß: 0.92 95% confidence interval 0.71, 1.13) were associated with a greater self-perception as having a mental illness (p < 0.05), providing evidence of convergent validity. As expected, we found that less intended stigmatising behaviour was associated with greater self-perceptions of having a mental illness (B: 0.18, 95% CI 0.07, 0.28). CONCLUSIONS: The SELF-I scale provides a method to gather insight into how young people, who may not identify as service users, perceive their own mental state and potential risk for developing a mental illness. This can be important for understanding perceived need for help and likelihood of using services among those with mental health problems.

Development of mental health indicators at the district level in Madhya Pradesh, India: mixed methods study.

BACKGROUND: Strengthening routine information systems for mental health can augment scale up of community mental health services in India and other low- and middle-income countries. Currently little routine data is available in Indian settings. This study aimed to develop a core set of indicators for monitoring mental health care in primary health care settings METHODS: By using a sequential exploratory mixed methods design, key mental health indicators measuring service delivery and system performance were developed for the context of Madhya Pradesh, India. The research design involved a situation analysis, and conducting a prioritisation exercise and consultation workshops with key stakeholders. RESULTS: This study resulted in nine key mental health indicators covering both mental health service delivery indicators and mental health system indicators for Sehore district of Madhya Pradesh. Mean indicator priority scores ranging from 4.48 to 3.78 were reported. CONCLUSIONS: This study demonstrated a phased approach to strengthen routine information systems for mental health at a primary care level in India. We recommend that similar research methods can be applied across comparable settings and these indicators can be adopted as a part of national routine information systems.

Interventions to reduce discrimination and stigma: the state of the art.

BACKGROUND: There is a rich literature on the nature of mental health-related stigma and the processes by which it severely affects the life chances of people with mental health problems. However, applying this knowledge to deliver and evaluate interventions to reduce discrimination and stigma in a lasting way is a complex and long-term challenge. METHODS: We conducted a narrative synthesis of systematic reviews published since 2012, and supplemented this with papers published subsequently as examples of more recent work. RESULTS: There is evidence for small to moderate positive impacts of both mass media campaigns and interventions for target groups in terms of stigma-related knowledge, attitudes, and intended behaviour in terms of desire for contact. However, the limited evidence from longer follow-up times suggests that it is not clear whether short-term contact interventions have a lasting impact. CONCLUSIONS: The risk that short-term interventions may only have a short-term impact suggests a need to study longer term interventions and to use interim process and outcome data to improve interventions along the way. There is scope for more thorough application of intergroup contact theory whenever contact is used and of evidence-based teaching and assessment methods when skills training is used for target groups.

Conditional Disclosure on Pathways to Care: Coping Preferences of Young People at Risk of Psychosis.

The interrelationship between stigma and help-seeking is under-researched among children and adolescents. This study explored stigma in relation to pathways to care among young people putatively in an early stage of increased risk of developing psychotic disorders. "Pathways to care" was defined as help-seeking and support from informal and formal resources, and increased risk was determined through the presence of persistent psychotic-like experiences and internalizing/externalizing psychopathology. Twenty-nine qualitative interviews were analyzed using thematic analysis. We defined the superordinate theme in these data as "conditional disclosure," a concept reflecting the rules and prerequisites that influenced how/whether participants sought help. Through parallels between these findings and established stigma theory, we examined how these conditions could be interpreted as influenced by stigma. Our findings demonstrate the influence of stigma on young people's perceptions of a range of pre-clinical symptoms, and on how they seek support for these symptoms.

Cultural adaptation of INDIGO mental health stigma reduction interventions using an ecological validity model in north India.

Background: The International Study of Discrimination and Stigma Outcomes (INDIGO) Partnership is a multi-country international research program in seven sites across five low- and middle-income countries (LMICs) in Africa and Asia to develop, contextually adapt mental health stigma reduction interventions and pilot these among a variety of target populations. The aim of this paper is to report on the process of culturally adapting these interventions in India using an established framework. Methods: As part of this larger program, we have contextualized and implemented these interventions from March 2022 to August 2023 in a site in north India. The Ecological Validity Model (EVM) was used to guide the adaptation and contextualization process comprising eight dimensions. Findings: Six dimensions of the Ecological Validity Model were adapted, namely language, persons, metaphors, content, methods, and context; and two dimensions, namely concepts and goals, were retained. Conclusion: Stigma reduction strategies with varied target groups, based on culturally appropriate adaptations, are more likely to be acceptable to the stakeholders involved in the intervention, and to be effective in terms of the program impact.

Social contact as a strategy to reduce stigma in low- and middle-income countries: A systematic review and expert perspectives.

Social contact (SC) has been identified as a promising strategy for stigma reduction. Different types of SC exist. Various scholars defined positive factors to strengthen SC. This study aims to investigate the application and effectiveness of SC as a strategy to reduce stigmatisation across stigmas, settings and populations in low- and middle-income countries (LMICs). We specifically examine the use of positive factors. A systematic review was conducted in twelve electronic databases using key terms related to stigma AND social contact AND intervention AND LMICs. Data were synthesised narratively. Study quality was assessed with the Joanna Briggs Institute critical appraisal checklists. Additionally, semi-structured interviews were used with first/corresponding authors of included publications to investigate their practical experiences with SC. Forty-four studies (55 publications) were identified. Various stigmas (n = 16) were targeted, including mental health (43%). Indirect (n = 18) and direct contact (n = 16) were used most frequently, followed by collaboration, imagined and vicarious contact, or a combination. The most applied additional strategy was education. Almost half of the studies, explicitly or implicitly, described positive factors for SC, such as PWLE training or disconfirming stereotypes. The majority suggested that SC is effective in reducing stigma, although inconsistent reporting overshadows conclusions. Perspectives of people with lived experience (PWLE) were infrequently included. Expert perspectives stressed the importance of contextualisation, PWLE participation, and evaluation of SC. This study provides an overview of SC as a stigma reduction strategy within LMICs. Conclusions about which type of SC is more effective or whether SC is more effective for a specific stigma category cannot be drawn. We recommend future research to strengthen reporting on effectiveness as well as PWLE perspective and SC processes, and to further critically examine the potential of SC. An overview of positive factors applied to strengthen SC is provided, which can stimulate reflection and guide future SC.

Exploring perspectives of stigma and discrimination among people with lived experience of mental health conditions: a co-produced qualitative study.

Background: Efforts to understand the mechanisms and consequences of mental health-related stigma and discrimination need to center the perspectives of people affected by these negative impacts, through research efforts that are led or co-led by people with lived experience (PWLE) of mental health conditions. Methods: This study used co-production principles to explore global perspectives of stigma and discrimination among people meeting the inclusion criteria of identifying as PWLEs and being willing to share their experiences of stigma and discrimination resulting from a diagnosis of a mental health condition, and who had also participated in anti-stigma activities. Participants were recruited online via a self-selecting snowball sampling method. Qualitative data were collected from respondents via an anonymous global online survey conducted between 12/01/2021 and 02/28/2022. The main outcomes assessed were open-ended, qualitative responses to questions exploring experiences of stigma and discrimination, experiences regarding diagnoses, language/terminology related to mental health, impact of stigma and discrimination, and involvement with anti-stigma interventions. Data were synthesised through digital text network analysis and thematic content analysis. Findings: A total of 198 respondents from over 30 countries across Europe, the Americas, Africa, Asia, and Australia/Oceania were included in the study. The results reflected five themes: 1) the role of language and words; 2) the role of media in perpetuating and reducing stigma; 3) societal reactions to mental health conditions and strategies to cope with these; 4) knowledge about activities to reduce stigma and discrimination and their impact; and 5) personal involvement in activities to reduce stigma and discrimination. Interpretation: The findings highlight that people with mental health conditions are aware of and experience stigma and discrimination across core domains of daily life. The importance of recognising the key role PWLEs can play in efforts to reduce stigma and discrimination was highlighted, and how they can be appropriately supported to contribute and have their experiential expertise recognised. Meaningful and authentic collaborations between PWLEs and other stakeholders can enhance the quality and relevance of strategies to reduce stigma and discrimination. This is, to our knowledge, the first study of its kind to use a co-production approach to explore experiences and reflections of stigma and discrimination related to mental health from a global perspective. However, the results are not broadly representative of the general PWLE population or suggestive of globally uniform experiences of stigma and discrimination. Funding: None.

Qualitative evidence regarding the experience of receiving and providing care for mental health conditions in non-specialist settings in low-income and middle-income countries: a systematic review of reviews.

QUESTION: This review of reviews synthesises qualitative evidence on the experiences of receiving and providing care and treatment for mental health conditions in non-specialist settings in low-income and middle-income countries (LMICs), and the factors that influence the provision and uptake of such services. STUDY SELECTION AND ANALYSIS: Database searches were conducted in PubMed/MEDLINE, EMBASE, PsycINFO, CINAHL, Scopus, African Index Medicus and Global Index Medicus, supplemented by screening repositories of systematic reviews protocols and contacting authors. The evidence synthesis drew on deductive and inductive approaches: a framework analysis approach was used for the initial coding structure, after which the results synthesis was refined further through reviewing and regrouping the initial coding through thematic synthesis principles. FINDINGS: Nine reviews met inclusion criteria and reported on a range of factors related to the provision and uptake of mental healthcare by non-specialist health workers in LMICs: (1) health worker competency, (2) availability of resources, (3) recipient-related and provider-related characteristics, (4) service accessibility, (5) sociocultural acceptability and (6) vulnerable groups for whom barrier to care were potentially exacerbated. CONCLUSIONS: This review provides nuanced and contextualised insights regarding the experiences of receiving and providing care for mental health conditions in LMICs, including barriers influencing service provision and uptake. It is important to ensure mental healthcare in non-specialist settings in LMICs is delivered in a manner which is feasible, acceptable and culturally appropriate in order to improve access to care, reducing stigma and promoting better overall health and well-being for individuals and communities.

Impact of mental health stigma on help-seeking in the Caribbean: Systematic review.

BACKGROUND: Mental health conditions often go untreated, which can lead to long-term poor emotional, social physical health and behavioural outcomes, and in some cases, suicide. Mental health-related stigma is frequently noted as a barrier to help seeking, however no previous systematic review has considered evidence from the Caribbean specifically. This systematic review aimed to address two research questions: (1) What is the impact of mental health stigma on help-seeking in the Caribbean? (2) What factors underlie the relationship between stigma and help-seeking in the Caribbean? METHODS: A systematic search was conducted across six electronic databases (Medline, Embase, Global Health, PsychInfo, Scopus and LILACS). The search included articles published up to May 2022. Experts in the field were consulted to provide publication recommendations and references of included studies were checked. Data synthesis comprised of three components: a narrative synthesis of quantitative findings, a thematic analysis of qualitative findings, and a meta-synthesis combining these results. RESULTS: The review included nine articles (reflecting eight studies) totaling 1256 participants. A conceptual model was derived from the meta-synthesis, identifying three themes in relation to mental health stigma and help-seeking in the Caribbean: (i) Making sense of mental health conditions'; (ii) Anticipated/Experienced stigma-related experiences and (iii) Individual characteristics. CONCLUSION: This review provides insights into the relationship between mental health stigma and help-seeking in the Caribbean based upon the current research evidence. This can be applied in the design of culturally appropriate future research, and to support policy and practice towards stigma reduction, and improved mental care help-seeking in the Caribbean.

"To fast or not to fast?" Ramadan and religiosity through the eyes of people with bipolar disorder: an exploratory study.

Background: The month of Ramadan, due to its changes in social rhythms, can seriously affect the course of bipolar disorder (BD). Therefore, psychiatrists sometimes find it necessary to discourage Ramadan practices, especially fasting, although taking part in this practice can give a sense of belonging and accomplishment to patients. Research on this subject is limited. Aim: The aim of the present work was to explore: (i) religious practices with special attention to Ramadan before and after the onset of BD, (ii) the perceptions and behaviors related to not fasting during Ramadan in patients with BD and their families' attitudes, (iii) religiosity and self-stigmatization and their relationships with religious practices, and (iv) the doctor-patient relationship around fasting. Methods: We conducted a retrospective, cross-sectional and descriptive study in clinically stabilized patients with BD in a public mental hospital and in a private psychiatric practice in Tunis, Tunisia. Socio-demographic and clinical data, as well as data related to general religious practices and Ramadan practices were collected using a self-established questionnaire. We assessed (i) religiosity of the patients with the Duke University Religion Index and (ii) self-stigma using the Internalized Stigma of Mental Illness scale. Results: Our sample consisted of 118 patients of whom 65.3% were fasting regularly before BD onset. More than half had stopped this practice following BD onset. Of the patients who did not fast, 16% felt guilty about this and 4.9% reported receiving negative remarks from their surroundings. High self-stigma scores were observed in 11% of the patients. Self-stigma was associated significantly with negative perception of not fasting, negative remarks regarding not fasting and taking both meals at regular times during Ramadan. The decision whether to fast or not was taken without seeking medical advice in 71.2% of the sample, and 16.9% of the sample reported that their psychiatrist had spontaneously approached the issue of Ramadan fasting. Conclusion: Religiosity and more specifically the practice of Ramadan remains an important point that should be considered when treating patients with psychiatric problems. It seems necessary that healthcare professionals should integrate the positive and the negative side of fasting into their reflections. Our results remain exploratory and encourage further work on the subject.

Assessing the priority of human rights and mental health: the PHRAME approach.

BACKGROUND: Protecting all human rights of people with mental health conditions is globally important. However, to facilitate practical implementation of rights, it is often necessary to decide which of these rights should be given priority, especially when they conflict with each other. AIMS: The aim of the Priorities of Human Rights and Mental Health (PHRAME) project is to develop a replicable approach to establish a proposed set of high-priority human rights of people with mental health conditions, to facilitate practical decision-making and implementation of such rights. METHOD: A two-stage Delphi-style study with stakeholders was conducted to generate a list of key rights of people with mental health conditions, and rank priorities among these rights in terms of feasibility, urgency and overall importance. RESULTS: The stakeholders in this study consistently ranked three rights as top priorities: (a) the right to freedom from torture, cruel inhuman treatment and punishment; (b) the right to health and access to services/treatment; and (c) the right to protection and safety in emergency situations. CONCLUSIONS: Insights from PHRAME can support decision-making about the priority to be given to human rights, to guide practical action. This approach can also be used to assess how human rights are prioritised in different settings and by different stakeholders. This study identifies the clear need for a central voice for people with lived experience in research and implementation of decisions about the priority of human rights, ensuring that action respects the opinion of people whose rights are directly affected.