Developing effective treatments for posttraumatic disorders among people with severe mental illness.

OBJECTIVE: The purpose of the study was to examine strategies for developing effective interventions for clients who have both serious mental illness and posttraumatic symptoms. METHODS: The authors conducted searches for articles published between 1970 and 2000, using MEDLINE, PsycLIT, and PILOTS. They assessed current practices, interviewed consumers and providers, and examined published and unpublished documents from consumer groups and state mental health authorities. RESULTS AND CONCLUSIONS: Exposure to trauma, particularly violent victimization, is endemic among clients with severe mental illness. Multiple psychiatric and behavioral problems are associated with trauma, but posttraumatic stress disorder (PTSD) is the most common and best-defined consequence of trauma. Mental health consumers and providers have expressed concerns about several trauma-related issues, including possible underdiagnosis of PTSD, misdiagnosis of other psychiatric disorders among trauma survivors, incidents of retraumatization in the mental health treatment system, and inadequate treatment for trauma-related disorders. Despite consensus that trauma and PTSD symptoms should be routinely evaluated, valid assessment techniques are not generally used by mental health care providers. PTSD is often untreated among clients with serious mental illness, or it is treated with untested interventions. It is important that policy makers, service system administrators, and providers recognize the prevalence and impact of trauma in the lives of people with severe mental illness. The development of effective treatments for this population requires a rational, orderly process, beginning with the testing of theoretically grounded interventions in controlled clinical trials.     

Lay beliefs regarding causes of mental illness in Nigeria: pattern and correlates

BACKGROUND: Although studies have shown that views about causation are strongly associated with stigmatising attitudes to mental illness, none have examined the correlates of such causal views in order to identify the population needed to be targeted for education. OBJECTIVES: To evaluate the pattern and correlates of lay beliefs regarding the causes of mental illness in south-western Nigeria. METHOD: A cross-sectional survey in which respondents (n = 2,078) were administered questionnaire detailing sociodemographic variables and perceived causation of mental illness. RESULTS: Beliefs in supernatural factors and the misuse of psychoactive substances were the most prevalent. While urban dwelling, higher educational status and familiarity with mental illness correlated with belief in biological and psychosicial causation, older age, rural dwelling, and lack of familiarity correlated with a belief in supernatural causation. Educational status had no effect on the belief in supernatural causation. CONCLUSION: Anti-stigma programmes need to incorporate these factors in order to identify the population at risk, who will actually benefit from targeted education regarding the causes of mental illness.     

Stigmatizing attitudes and beliefs about treatment and psychiatric medications for children with mental illness

OBJECTIVES: Data on community responses to two treatment issues critical for children and adolescents with mental health problems are addressed: stigma associated with receiving mental health care and the willingness to use psychiatric medication. METHODS: Using a representative sample of the U.S. population, the investigators interviewed 1,393 noninstitutionalized adult participants in the National Stigma Study-Children (NSS-C) (response rate 70%; margin of error +/- 4%). RESULTS: Many respondents believed that stigma results from mental health treatment during childhood (45% reported likely rejection at school) and that stigma continues to have negative ramifications into adulthood (43%). More than half (57%) were skeptical about confidentiality, and more than one-third (35%) expected parents of children with mental illness to experience self-stigma. Most respondents believed that psychiatric medications affect development (68%), give children a flat, "zombie"-like affect (53%), and delay solving "real" behavior-related problems (66%). Most (86%) believed that physicians overmedicate children for common behavioral problems. Women and persons with more education rather than less perceived less stigma resulting from treatment but reported more negative views on medication. Beliefs in medication efficacy and trust in physicians were associated with more positive cultural beliefs. CONCLUSIONS: Data on the contemporary cultural context surrounding treatment for children's mental health issues revealed substantial stigma concerns, particularly surrounding medication options. These beliefs and attitudes cannot be easily inferred from adults' sociodemographic characteristics.     

Three strategies for changing attributions about severe mental illness

The effects of three strategies for changing stigmatizing attitudes--education (which replaces myths about mental illness with accurate conceptions), contact (which challenges public attitudes about mental illness through direct interactions with persons who have these disorders), and protest (which seeks to suppress stigmatizing attitudes about mental illness)--were examined on attributions about schizophrenia and other severe mental illnesses. One hundred and fifty-two students at a community college were randomly assigned to one of the three strategies or a control condition. They completed a questionnaire about attributions toward six groups--depression, psychosis, cocaine addiction, mental retardation, cancer, and AIDS--prior to and after completing the assigned condition. As expected, results showed that education had no effect on attributions about physical disabilities but led to improved attributions in all four psychiatric groups. Contact produced positive changes that exceeded education effects in attributions about targeted psychiatric disabilities: depression and psychosis. Protest yielded no significant changes in attributions about any group. This study also examined the effects of these strategies on processing information about mental illness.     

Idealized cultural beliefs about gender: implications for mental health

Background In this paper, we examined the relationship between culture-specific ideals (chastity, masculinity, caste beliefs) and self-esteem, shame and depression using an idealized cultural model proposed by Mahalingam (2006, In: Mahalingam R (ed) Cultural psychology of immigrants. Lawrence Erlbaum, Mahwah, NJ, pp 1–14). Methods Participants were from communities with a history of extreme male-biased sex ratios in Tamilnadu, India (N = 785). Results We hypothesized a dual-process model of self-appraisals suggesting that achieving idealized cultural identities would increase both self-esteem and shame, with the latter leading to depression, even after controlling for key covariates. We tested this using structural equation modeling. The proposed idealized cultural identities model had an excellent fit (CFI = 0.99); the effect of idealized identities on self-esteem, shame and depression differed by gender. Conclusions Idealized beliefs about gender relate to psychological well-being in gender specific ways in extreme son preference communities. We discuss implications of these findings for future research and community-based interventions.     

EPA Guidance on tobacco dependence and strategies for smoking cessation in people with mental illness

Tobacco dependence is the most common substance use disorder in adults with mental illness. The prevalence rates for tobacco dependence are two to four times higher in these patients than in the general population. Smoking has a strong, negative influence on the life expectancy and quality of life of mental health patients, and remains the leading preventable cause of death in this group. Despite these statistics, in some countries smokers with mental illness are disadvantaged in receiving intervention and support for their tobacco dependence, which is often overlooked or even tolerated. This statement from the European Psychiatric Association (EPA) systematically reviews the current evidence on tobacco dependence and withdrawal in patients with mental illness and their treatment. It provides seven recommendations for the core components of diagnostics and treatment in this patient group. These recommendations concern: (1) the recording process, (2) the timing of the intervention, (3) counselling specificities, (4) proposed treatments, (5) frequency of contact after stopping, (6) follow-up visits and (7) relapse prevention. They aim to help clinicians improve the care, health and well-being of patients suffering from mental illness.     

Lay beliefs about the causes of mental disorders: a new methodological approach

So far, researchers have, for the most part, used lists of Likert-scaled items in their quantitative analysis of lay beliefs about the causes of mental disorders. With the help of factor analyses they have then sought to identify the independent dimensions of the attitudinal space. In contrast, it is the aim of multiple unidimensional unfolding, which shall be presented in this paper, to establish a latent dimension of the order of preference regarding the causes offered as an explanation for the development of mental disorders. Using data from a representative survey examining the attitude of the general public of the new Länder of the Federal Republic of Germany towards mental disorders, which was conducted during 1993, it can be shown that 11 of the 15 causal factors offered may be arranged along an unfolding scale. The centre of the scale was characterized by the item God's will or fate. Psychosocial stress factors constituted one pole of the scaie, personality disorders, the other. In between we found both external and biological influences over which the afflicted individuals had no control. Analogies to the concept of locus of control are discussed.     

Self-stigma in people with mental illness

Persons with mental illnesses such as schizophrenia may internalize mental illness stigma and experience diminished self-esteem and self-efficacy. In this article, we describe a model of self-stigma and examine a hierarchy of mediational processes within the model. Seventy-one individuals with serious mental illness were recruited from a community support program at an outpatient psychiatry department of a community hospital. All participants completed the Self-Stigma of Mental Illness Scale along with measures of group identification (GI), perceived legitimacy (PL), self-esteem, and self-efficacy. Models examining the steps involved in self-stigma process were tested. Specifically, after conducting preliminary bivariate analyses, we examine stereotype agreement as a mediator of GI and PL on stigma self-concurrence (SSC); SSC as a mediator of GI and PL on self-efficacy; and SSC as a mediator of GI and PL on self-esteem. Findings provide partial support for the proposed mediational processes and point to GI, PL, and stereotype agreement as areas to be considered for intervention.     

Services for families of people with mental illness

Clearly all of the issues and disagreements about interventions with families of people with serious mental illness could not be resolved in one meeting. What did become evident was the depth of the schisms that separate various models. Differences in supporting theory and practice between models, which may seem minimal to the casual observer, actually are grounded in the goal and target of the service. We suggest that a need remains to create a comprehensive system that serves the individual needs of the consumer. The current models each have a role. Dogmatic claims that any particular model is best for all families should be viewed as suspect. The first step in creating such a system is to determine which sets of needs are met by each model. Such knowledge would help providers offer services that meet specific needs in their communities and allow them to educate families about the services. Once families know what outcome they can expect, they can choose the service most appropriate for them. More informed consumer choices might increase the appropriate utilization of services and improve specific service outcomes.     

Skills training for people with severe mental illness

There is a growing empirical literature on psychosocial rehabilitation strategies for schizophrenia and other severe mental illnesses. Three of the best-supported and most promising approaches were reviewed: social skills training (SST), cognitive behavior therapy (CBT), and cognitive remediation (CR). Of the three, SST has the strongest empirical support and can be considered an evidence-based treatment. However, it is appropriate as a targeted treatment for social impairment, not as a broad based treatment for schizophrenia. CBT has only recently been applied to patients with psychotic disorders and the preliminary results are promising for reducing distress associated with residual psychotic symptoms. All but a handful of trials have been carried out in the context of the public health system in the UK with specially selected patients. Consequently, it is not yet clear if it would be effective in public health systems in the US, with highly impaired patients, or for patients with comorbid substance abuse. There is an extensive literature documenting that a variety of training techniques can improve performance on neuropsychological tests, and there is a growing literature of more clinically relevant CR trials that have produced small to medium effect sizes. No studies have yet demonstrated a clinically significant effect on community functioning. This is a promising area for further research, but CR, like CBT, does not have a sufficient evidentiary base for widespread dissemination to the public mental health system at this time.     

Cardiovascular risk factors for people with mental illness

OBJECTIVE: The objective of this study was to document the prevalence of risk factors for cardiovascular disease among people with chronic mental illness. METHOD: A cross-sectional survey was conducted of 234 outpatients attending a community mental health clinic in the North-western Health Care Network in Melbourne, Australia. Prevalence of smoking, alcohol consumption, body mass index, hypertension, salt intake, exercise and history of hypercholesterolemia was assessed. RESULTS: Compared with a community sample, the mentally ill had a higher prevalence of smoking, overweight and obesity, lack of moderate exercise, harmful levels of alcohol consumption and salt intake. No differences were found on hypertension. Men, but not women, with mental illness were less likely to undertake cholesterol screening. CONCLUSIONS: Psychiatric outpatients have a high prevalence of cardiovascular risk factors which may account for the higher rate of cardiovascular mortality among the mentally ill. Further research is needed to trial and evaluate interventions to effectively modify risk factors in this vulnerable population.