We identified references for this Review through searches of Medline, PsycINFO, the Cochrane Library, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Social Science Citation Index (SSCI), and Global Health for articles published from January, 1970, to December, 2012. The search terms used are shown in the panel. In addition we did a Google Advanced Search focusing on low-income and middle-income countries (LMICs; figure). The searches were not limited by language. All
ReviewEvidence for effective interventions to reduce mental-health-related stigma and discrimination
Section snippets
Definitions and models of stigma and discrimination
Research on mental-health-related stigma and discrimination has increased steadily over the past few decades, although until recently, published work has been mostly descriptive and has not included intervention studies.1, 2 Earlier work also tended to focus on public attitudes towards people with mental illness rather than on direct experiences of people with these conditions.3, 4
Several theoretical approaches to mental-health-related stigma and discrimination have been developed including
Behavioural consequences of stigma
The behavioural consequences of stigma (ie, discrimination) can compound the disabilities related to the primary symptoms of mental illness, and lead to disadvantages in many aspects of life, such as personal relationships, education, and work.1 Such discrimination can limit opportunities through, for example, loss of income, unemployment, reduced access to housing or health care.3
In addition to experiences of direct discrimination from others, people with mental illness might be disadvantaged
Literature search methods
We assimilated information from systematic reviews on various types of anti-stigma intervention that could provide good evidence for short-term effectiveness in high-income countries. We then focused our literature search on primary studies of medium-term to long-term outcomes, and on the effectiveness of anti-stigma interventions in low-income and middle-income countries (LMICs), two research areas that have not previously been reviewed. We searched six electronic databases for potentially
Short-term effectiveness of interventions in high-income countries: evidence from systematic reviews
The studies included in the systematic reviews had substantial methodological and clinical heterogeneity, and consequently meta-analysis was rarely undertaken. The data suggested that interventions are usually able to produce short-term to medium-term knowledge and, though less often, attitudinal improvements.26, 27 Variation in the results might be due to differences in the intensity of interventions that aim to increase knowledge compared with those aiming for attitude change, or might
Interventions targeted to the general public
Systematic reviews, controlled interventions, repeated cross-sectional surveys and longitudinal panel studies have been used to determine the effect of targeting the general public to reduce stigma. Until very recently these studies have assessed knowledge or attitude change, or both, but have not assessed the impact on behaviour. A meta-analysis by Corrigan and colleagues29 that includes 79 intervention studies to address public stigma demonstrated that both education and social contact were
Interventions for people with mental illness
Interventions have also been developed and tested that aim to reduce self-stigma among people with mental illness.47 There is evidence to suggest that such interventions are effective. For example, Mittal and colleagues32 showed that of the 14 studies assessed, eight conferred benefits in terms of self-stigma reduction, usually with effect sizes in the range 0·2–0·5 (conventionally considered to be small to moderately large effects). Most self-stigma reduction strategies consist of group-level
Interventions for students
Anti-stigma interventions for school and college students have been studied in several countries. Interventions primarily involved either mental health education, or education combined with direct contact with someone who has a mental health problem. A systematic review of anti-stigma interventions for those at school, reported that overall the methodological quality of the studies is mixed, with only two randomised trials, leading one reviewer to find it difficult to draw overall conclusions.33
Interventions with health-care staff
There is accumulating evidence that, perhaps paradoxically, many people with mental illness report that health personnel, providing both mental and physical health services, are an important source of stigma and discrimination in many countries worldwide.58, 59 Mental health professionals could be stigmatisers, stigma recipients, and agents of destigmatisation.60 Systematic disregard for the physical health needs of people with mental illness includes the problem of misattribution of physical
Other specific target groups
Interventions to reduce stigmatisation among a diverse range of other target groups that include military personnel,71 elite athletes,72 teachers,73 and civil servants38 have also been carried out. The findings are remarkably similar to the groups already described, with improvement in knowledge in about half of the studies, benefit in terms of attitudes in most studies, and sustained improvement at medium-term follow-up for about half of the reports.
Stigma-related intervention studies in low-income and middle-income countries
Stigma-related intervention studies in LMICs are uncommon, generally of poor quality and have only short-term follow-up, which is in line with research in other aspects of global mental health.74 We identified 13 studies from LMIC settings, eight with less than a 4 week follow-up and five with longer-term follow-up. Six of the LMIC studies were from upper-middle income countries and two were from lower-middle income countries. There were no studies meeting our criteria from low-income
Studies that examined medium-term and long-term effectiveness
Most studies that measured outcomes beyond 4 weeks follow-up reported some evidence of effectiveness in improving knowledge and attitudes but not for behavioural outcomes. The different intervention types varied in their medium-term or long-term effectiveness. Mental health education or information interventions seemed to be the most effective type of intervention with regards to outcomes at 4 or more week's follow-up, although education or information combined with direct or indirect contact,
Discussion
The most widely used intervention types tested as potential active ingredients in the intervention studies were education or information (43 studies), and variants of social contact (12 studies)—ie, contact between people with and without mental illness29 (table 2). Results from our analysis of systematic reviews supported social contact as the most effective intervention for adults. Results from our analysis of primary studies showed that social contact is an effective intervention for adults
Search strategy and selection criteria
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