Elsevier

The Lancet

Volume 387, Issue 10023, 12–18 March 2016, Pages 1123-1132
The Lancet

Review
Evidence for effective interventions to reduce mental-health-related stigma and discrimination

https://doi.org/10.1016/S0140-6736(15)00298-6Get rights and content

Summary

Stigma and discrimination in relation to mental illnesses have been described as having worse consequences than the conditions themselves. Most medical literature in this area of research has been descriptive and has focused on attitudes towards people with mental illness rather than on interventions to reduce stigma. In this narrative Review, we summarise what is known globally from published systematic reviews and primary data on effective interventions intended to reduce mental-illness-related stigma or discrimination. The main findings emerging from this narrative overview are that: (1) at the population level there is a fairly consistent pattern of short-term benefits for positive attitude change, and some lesser evidence for knowledge improvement; (2) for people with mental illness, some group-level anti-stigma inventions show promise and merit further assessment; (3) for specific target groups, such as students, social-contact-based interventions usually achieve short-term (but less clearly long-term) attitudinal improvements, and less often produce knowledge gains; (4) this is a heterogeneous field of study with few strong study designs with large sample sizes; (5) research from low-income and middle-income countries is conspicuous by its relative absence; (6) caution needs to be exercised in not overgeneralising lessons from one target group to another; (7) there is a clear need for studies with longer-term follow-up to assess whether initial gains are sustained or attenuated, and whether booster doses of the intervention are needed to maintain progress; (8) few studies in any part of the world have focused on either the service user's perspective of stigma and discrimination or on the behaviour domain of behavioural change, either by people with or without mental illness in the complex processes of stigmatisation. We found that social contact is the most effective type of intervention to improve stigma-related knowledge and attitudes in the short term. However, the evidence for longer-term benefit of such social contact to reduce stigma is weak. In view of the magnitude of challenges that result from mental health stigma and discrimination, a concerted effort is needed to fund methodologically strong research that will provide robust evidence to support decisions on investment in interventions to reduce stigma.

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

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

References (101)

  • A Rahman et al.

    Randomised trial of impact of school mental-health programme in rural Rawalpindi, Pakistan

    Lancet

    (1998)
  • TF Pettigrew et al.

    Recent advances in intergroup contact theory

    Int J Intercult Relat

    (2011)
  • RO Ogedengbe

    Prior contacts and perceptions of previously mentally disturbed patients

    Int J Nurs Stud

    (1993)
  • K Hawton et al.

    Risk factors for suicide in individuals with depression: a systematic review

    J Affect Disord

    (2013)
  • G Thornicroft

    Most people with mental illness are not treated

    Lancet

    (2007)
  • G Thornicroft

    Shunned: Discrimination against people with mental illness

    (2006)
  • L Yang et al.

    Stigma of Mental Illness

  • BG Link et al.

    Conceptualising Stigma

    Am Sociol Rev

    (2001)
  • P Corrigan

    Mental health stigma as social attribution: Implications for research methods and attitude change

    Clin Psychol Sci Pract

    (2000)
  • P Corrigan et al.

    The paradox of self-stigma and mental illness

    Clin Psychol Sci Pract

    (2006)
  • PW Corrigan et al.

    Self-stigma and the “why try” effect: impact on life goals and evidence-based practices

    World Psychiatry

    (2009)
  • Behaviour change at population, community and individual levels

  • G Thornicroft et al.

    Stigma: ignorance, prejudice or discrimination?

    Br J Psychiatry

    (2007)
  • S Clement et al.

    Disability hate crime and targeted violence and hostility: a mental health and discrimination perspective

    J Ment Health

    (2011)
  • G Thornicroft et al.

    Discrimination in health care against people with mental illness

    Int Rev Psychiatry

    (2007)
  • PW Corrigan et al.

    Structural levels of mental illness stigma and discrimination

    Schizophr Bull

    (2004)
  • Link BG, Phelan JC. On stigma and its public health implications. Stigma and global health: developing a research...
  • G Thornicroft

    Premature death among people with mental illness

    BMJ

    (2013)
  • G Thornicroft

    Physical health disparities and mental illness: the scandal of premature mortality

    Br J Psychiatry

    (2011)
  • Convention on the rights of persons with disabilities

    (2006)
  • J Randall et al.

    Development of the ITHACA toolkit for monitoring human rights and general health care in psychiatric and social care institutions

    Epidemiol Psychiatr Sci

    (2013)
  • S Clement et al.

    Development and psychometric properties the barriers to access to care evaluation scale (BACE) related to people with mental ill health

    BMC Psychiatry

    (2012)
  • S Clement et al.

    What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies

    Psychol Med

    (2015)
  • C Henderson et al.

    Mental illness stigma, help seeking, and public health programs

    Am J Public Health

    (2013)
  • R Padmavati et al.

    A qualitative study of religious practices by chronic mentally ill and their caregivers in South India

    Int J Soc Psychiatry

    (2005)
  • MC Angermeyer et al.

    Courtesy stigma—a focus group study of relatives of schizophrenia patients

    Soc Psychiatry Psychiatr Epidemiol

    (2003)
  • S Hinshaw

    The mark of shame

    (2007)
  • R Thara et al.

    Women with schizophrenia and broken marriages–doubly disadvantaged? Part II: family perspective

    Int J Soc Psychiatry

    (2003)
  • JP Higgins et al.

    The Cochrane Collaboration's tool for assessing risk of bias in randomised trials

    BMJ

    (2011)
  • S Clement et al.

    Mass media interventions for reducing mental health-related stigma

    Cochrane Database Syst Rev

    (2013)
  • S Yamaguchi et al.

    Effects of short-term interventions to reduce mental health-related stigma in university or college students: a systematic review

    J Nerv Ment Dis

    (2013)
  • N Mansouri et al.

    The change in attitude and knowledge of health care personnel and general population following trainings provided during integration of mental health in Primary Health Care in Iran: a systematic review

    Int J Ment Health Syst

    (2009)
  • PW Corrigan et al.

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

    Psychiatr Serv

    (2012)
  • A Holzinger et al.

    Evaluation of target-group oriented interventions aimed at reducing the stigma surrounding mental illness

    Psychiatr Prax

    (2008)
  • D Mittal et al.

    Empirical studies of self-stigma reduction strategies: a critical review of the literature

    Psychiatr Serv

    (2012)
  • HM Schachter et al.

    Effects of school-based interventions on mental health stigmatization: a systematic review

    Child Adolesc Psychiatry Ment Health

    (2008)
  • AJ Sogaard et al.

    The Norwegian Mental Health Campaign in 1992. Part II: changes in knowledge and attitudes

    Health Educ Res

    (1995)
  • ES Paykel et al.

    Changes in public attitudes to depression during the Defeat Depression Campaign

    Br J Psychiatry

    (1998)
  • AH Crisp

    Every family in the land. Understanding prejudice and discrimination against people with mental illness (revised edn)

    (2004)
  • AF Jorm et al.

    Mental health first aid training for high school teachers: a cluster randomized trial

    BMC Psychiatry

    (2010)
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