A qualitative study: experiences of stigma by people with mental health problems

Objectives

Prior research has examined various components involved in the impact of public and internalized stigma on people with mental health problems. However, studies have not previously investigated the subjective experiences of mental health stigma by those affected in a non‐statutory treatment‐seeking population.

Design

An in‐depth qualitative study was conducted using thematic analysis to investigate the experiences of stigma in people with mental health problems.

Methods

Eligible participants were recruited through a local mental health charity in the North West of England. The topic of stigma was examined using two focus groups of thirteen people with experience of mental health problems and stigma.

Results

Two main themes and five subthemes were identified. Participants believed that (1) the ‘hierarchy of labels’ has a profound cyclical impact on several levels of society: people who experience mental health problems, their friends and family, and institutional stigma. Furthermore, participants suggested (2) ways in which they have developed psychological resilience towards mental health stigma.

Conclusions

It is essential to utilize the views and experiences gained in this study to aid understanding and, therefore, develop ways to reduce the negative impact of public and internal stigma.

Practitioner points

• People referred to their mental health diagnosis as a label and associated that label with stigmatizing views.
• Promote awareness and develop improved strategies (e.g., training) to tackle the cyclical impact of the ‘hierarchy of labels’ on people with mental health problems, their friends and family, and institutional stigma.
• Ensure the implementation of clinical guidelines in providing peer support to help people to combat feeling stigmatized.
• Talking about mental health in psychological therapy or health care professional training helped people to take control and develop psychological resilience.

     

The interaction of exposure to adverse childhood and combat experiences on the current mental health of new post-9/11 veterans

Military veterans have greater exposure to adverse childhood experiences (ACEs) than civilians and many also encounter warfare exposures, which can increase the likelihood of mental health problems. The purpose of this study was to test an interaction between childhood traumas and warfare exposures on the mental health of a sample of nearly 10,000 new post-9/11 veterans. Results revealed that male veterans exposed to one or two ACEs, but no warfare, were more likely to experience anxiety, depression, suicidal thinking, and angry outbursts than the reference group (i.e., no ACEs and no warfare exposure). Female veterans exposed to one or two ACEs, but no warfare, were only more likely to experience suicidal thinking. Male and female veterans exposed to three or more ACEs and no warfare were more likely to experience probable posttraumatic stress disorder (PTSD), anxiety, depression, suicidality, and angry outbursts. Among those veterans who experienced corollaries of combat only (e.g., seeing someone killed or seriously wounded), male, but not female veterans were more likely to have probable PTSD, anxiety, and depression. Veterans exposed to warfare (i.e., combat and the corollaries of combat), irrespective of ACEs exposure, were the most likely to report mental health symptoms. Implications for community-based mental health services are discussed.     

Bipolar disorder and stigma: A systematic review of the literature

Aim

The degree to which bipolar disorder is stigmatised by the public and the extent of internalised stigma for people with this disorder, their families, and carers has been a relatively neglected area of research. This review aimed to determine what is currently known about stigma and bipolar disorder.

Method

A systematic search of the literature was conducted to identify publications which investigated public attitudes and/or beliefs about bipolar disorder or explored internalised stigma in bipolar disorder. The electronic databases PsychINFO, Medline, Embase, and Web of Science were searched for articles published between 1992 and 2012.

Results

Twenty five articles met the reviews inclusion criteria. There are inconsistent findings regarding public stigma, although there is some evidence that bipolar disorder is viewed more positively than schizophrenia and less positively than depression. There is a moderate to high degree of internalised stigma in bipolar disorder, although the literature raises questions regarding its ubiquity in this population.

Limitations

Limiting the search by year of publication and excluding studies where stigma was not the main focus could mean stigma has wider implications than were identified.

Conclusions

This review is the first systematic synthesis of research relating to stigma and bipolar disorder. In comparison to research on other mental health problems, there is a dearth of literature exploring stigma in bipolar disorder. The literature is largely inconclusive. Future research is needed to replicate tentative findings and address methodological limitations before the field can move on to the development of anti-stigma interventions.     

Dispositional optimism buffers combat veterans from the negative effects of warzone stress on mental health symptoms and work impairment

The study examined dispositional optimism s role in buffering the effect of warzone stress on mental health symptoms and mental health symptoms on work impairment. A total of 2,439 soldiers from an active-duty brigade combat team were surveyed following a 12-month deployment to Iraq. Posttraumatic stress disorder (PTSD) symptoms, depression symptoms, combat exposure, deployment demands, and work impairment were measured. Soldiers higher in dispositional optimism showed weaker relationships between combat exposure and PTSD symptoms, and between deployment demands and PTSD and depression symptoms. Dispositional optimism also buffered mental health symptom effects on work impairment. Dispositional optimism may protect soldiers from warzone stress and mental health symptoms. Potential mechanisms explaining how dispositional optimism may serve as a protective factor are discussed.     

Recovery style and stigma in psychosis: the healing power of integrating

Introduction. Persecutory delusions are a very common symptom in psychotic disorders and represent a considerable cost for both patients and for society. The way in which a person faces their psychotic disorder (i.e., recovery style) has impact on their recovery. The impact of coping style as a moderator in the course of their illness has not been studied sufficiently in persecutory delusions. In addition, internalised stigma is a common process in psychosis that not only might affect emotional distress, but might also shape recovery style. The goal of this study was to examine the moderator role of recovery style between internalised stigma and emotional distress in people with persecutory delusions. Methods. All 50 people with persecutory beliefs were assessed by the Recovery Style Questionnaire, the Beck Anxiety Inventory, Beck Depression Inventory, Second Edition, and Internalised Stigma of Mental Illness. Results. Moderation analysis showed that participants with a sealing-over recovery style had high levels of depression when they experienced internalised stigma and low levels of depression only when internalised stigma was low. However, participants with an integration recovery style presented similar levels of depression regardless of the level of their internalised stigma. Conclusions. Findings suggest the moderator role of recovery style between internalised stigma and depression in people with persecutory delusions.     

A central dilemma in the mental health sector: Structural imbalance

Mental health services provision is persistently criticised regarding resource inadequacy. Services are also subject to another dilemma, “structural imbalance”. This study demonstrates the dimensions of structural imbalance in Australia's mental health sector by recourse to the 1997 Australian Bureau of Statistics national survey of mental health and wellbeing. This study also examines the concept by reference to the Australian Government's announced COAG initiatives (April 2006), and State government responses (July 2006). The two dimensions of structural imbalance are, first, that some people with no clinical mental illness consume mental health services and, second, that other people have clinical manifestations of mental illness and (for various reasons) do not consume mental health services; the present study shows how the situations coexist. “Throwing more money” at the pre‐existing structures may do nothing to address the structural imbalance problem. Remedies are discussed by reference to the reforms undertaken in the British National Health Service in recent years.     

Addressing mental health disparities through clinical competence not just cultural competence: the need for assessment of sociocultural issues in the delivery of evidence-based psychosocial rehabilitation services

Recognition of ethnic/racial disparities in mental health services has not directly resulted in the development of culturally responsive psychosocial interventions. There remains a fundamental need for assessment of sociocultural issues that have been linked with the expectations, needs, and goals of culturally diverse consumers with severe and persistent mental illness. The authors posit that embedding the assessment of sociocultural issues into psychosocial rehabilitation practice is one step in designing culturally relevant empirically supported practices. It becomes a foundation on which practitioners can examine the relevance of their interventions to the diversity encountered in everyday practice. This paper provides an overview of the need for culturally and clinically relevant assessment practices and asserts that by improving the assessment of sociocultural issues the clinical competence of service providers is enhanced. The authors offer a conceptual framework for linking clinical assessment of sociocultural issues to consumer outcomes and introduce an assessment tool adapted to facilitate the process in psychosocial rehabilitation settings. Emphasizing competent clinical assessment skills will ultimately offer a strategy to address disparities in treatment outcomes for understudied populations of culturally diverse consumers with severe and persistent mental illness.     

Posttraumatic sleep disturbances in veterans: A pilot randomized controlled trial of cognitive behavioral therapy for insomnia and imagery rehearsal therapy

Objectives

Posttraumatic stress disorder (PTSD) is associated with sleep disturbances including insomnia and nightmares. This study compared cognitive behavioral therapy for insomnia (CBT-I) with CBT-I combined with imagery rehearsal therapy (IRT) for nightmares to evaluate if the combined treatment led to greater reductions in trauma-related sleep disturbances in Australian veterans.

Methods

Veterans with diagnosed PTSD, high insomnia symptom severity, and nightmares (N = 31) were randomized to eight group CBT-I sessions or eight group CBT-I + IRT sessions. Self-reported sleep, nightmare, and psychological measures (primary outcome: Pittsburgh Sleep Quality Index), and objective actigraphy data were collected; the effect of obstructive sleep apnea (OSA) risk on treatment outcomes was also examined.

Results

No treatment condition effects were detected for the combined treatment compared to CBT-I alone, and no moderating effect of OSA risk was detected. On average, participants from both groups improved on various self-report measures over time (baseline to 3 months posttreatment). Despite the improvements, mean scores for sleep-specific measures remained indicative of poor sleep quality. There were also no significant differences between the groups on the actigraphy indices.

Conclusions

The findings indicate that there is potential to optimize both treatments for veterans with trauma-related sleep disturbances.     

Effects of a multilingual information website intervention on the levels of depression literacy and depression-related stigma in Greek-born and Italian-born immigrants living in Australia: a randomized controlled trial

Background

Little is known about the efficacy of Internet-based information interventions in increasing depression literacy or reducing depression stigma and depressive symptoms in people from non–English-speaking backgrounds.

Objective

Our objective was to investigate the effects of Multicultural Information on Depression Online (MIDonline), an Internet-based multilingual depression-specific information resource, on depression literacy, depression stigma, and depressive symptoms in Greek-born and Italian-born immigrants to Australia.

Method

In all, 202 Greek- and Italian-born immigrants aged 48 to 88 years were randomly allocated to an online depression information intervention (n =110) or a depression interview control group (n = 92). Participants allocated to the information intervention only had access to the website during the 1- to 1.5-hour intervention session. The primary outcome measures were depression literacy (depression knowledge), personal stigma (personal stigma toward people with a mental illness), perceived stigma (participants’ views about the probable attitude of the general community toward people with mental illness), and depressive symptoms. Depression literacy, personal and perceived stigma, and depressive symptoms were assessed at preassessment, postassessment, and at a 1-week follow-up assessment. The trial was undertaken at Monash University, Melbourne, Australia. Randomization and allocation to trial group were carried out using a computer-generated table.

Results

For depression literacy, there was a significant difference between the MIDonline and the control group with those in the MIDonline intervention displaying higher depression literacy scores postassessment (F_1,178 = 144.99, P < .001) and at the follow-up assessment (F_1,178 = 129.13, P < .001) than those in the control group. In addition, those in the MIDonline intervention showed a significantly greater decrease in mean personal stigma scores postassessment (F_1,178 = 38.75, P < .001) and at the follow-up assessment (F_1,176 = 11.08, P = .001) than those in the control group. For perceived stigma, there was no significant difference between the MIDonline intervention and the control group at postassessment (F_1,178 = 0.60, P = .44) and at the follow-up assessment (F_1,176 = 1.06, P = .30). For level of depression, there was no significant difference between the MIDonline intervention and the control group at preassessment (F_1,201 = 0.56, P = .45), postassessment (F_1,178 = 0.03, P = .86), or at the follow-up assessment, (F _1,175 = 1.71, P = .19). Within group effect sizes for depression literacy were −1.78 (MIDonline) and −0.07 (control); for personal stigma, they were 0.83 (MIDonline) and 0.06 (control); for perceived stigma, they were 0.14 (MIDonline) and 0.16 (control); and for depressive symptoms, they were 0.10 (MIDonline) and 0.10 (control).

Conclusions

Current results suggested that the Internet may be a feasible and effective means for increasing depression knowledge and decreasing personal stigma in non–English-speaking immigrant populations residing in English-speaking countries. The lack of change in perceived stigma in this trial is consistent with results in other trials examining online depression stigma interventions in English-speaking groups.

Trial Registration

ISRCTN76460837; http://www.controlled-trials.com/ISRCTN76460837 (Archived by WebCite at http://www.webcitation.org/5xjxva4Uq)     

A phenomenological inquiry into the experience of sleep: Perspectives of US military veterans with insomnia and serious mental illness

The majority of people with serious mental illness experience insomnia, and insomnia is one of the most frequent reasons for mental health referrals in the Veterans Health Administration. Insomnia also represents a critical obstacle to mental health recovery. Little is known about how military veterans with mental health problems conceptualize their sleep and sleep problems; such information may uncover new avenues for research and treatment. Therefore, the purpose of this study was to explore how veterans with serious mental illness and insomnia experience and understand their sleep, towards the aim of identifying these new avenues. Participants included 20 veterans with insomnia and serious mental illness (i.e. schizophrenia spectrum, bipolar or major depressive disorders, with serious functional impairments). Data were collected via an inductive phenomenological approach using semi‐structured interviews. We identified five themes: Sleep to Recharge; Sleep as a Fight; Sleep as Safety or Escape; Sleep as Dangerous; and Military Influence. Participants' relationship with sleep was complex; many associated it with intrusive and troubling hallucinations, paranoia and military experiences, yet at the same time desired sleep for its potential to liberate them from distress. Military mindsets both helped and hindered sleep. These results extend existing models of insomnia development and maintenance, and illuminate phenomena previously unidentified in this underserved veteran population. Clinical and theoretical implications are discussed, as well as new research directions for enhancing therapeutic efficacy.     

The effects of sustained COVID-19 emergency and restrictions on the mental health of subjects with serious mental illness: A prospective study

Few longitudinal studies have so far investigated the impact of sustained COVID-19 among people with pre-existing psychiatric disorders. We conducted a prospective study involving people with serious mental illness (n = 114) and healthy controls (n = 41) to assess changes in the Perceived Stress Scale, Generalized Anxiety Disorder Scale, Patient Health Questionnaire, and Specific Psychotic Experiences Questionnaire scores 18 months after the COVID-19 pandemic outset. Subjects underwent interviews with a mental health professional in April 2020 and at the end of the local third wave (October 2021). A significant increase in perceived stress was found in healthy controls, especially females. Psychiatric patients showed a significant worsening of anxiety symptoms compared to baseline records (t = −2.3, p = 0.036). Patients who rejected vaccination had significantly higher paranoia scores compared to those willing to get vaccinated (U = 649.5, z = −2.02, p = 0.04). These findings indicate that COVID-19's sustained emergency may cause enduring consequences on mental health, soliciting further investigations.     

Sex-specific role of alexithymia in associations between parental bonding and mental health: A moderated mediation model

Objective

This study aimed to explore the role of alexithymia and potential sex differences in the associations between perceived parental bonding and mental health.

Methods

The sample consists of 2421 parents from the FinnBrain Birth Cohort Study who completed the parental bonding instrument, the Toronto alexithymia scale, the Edinburgh postnatal depression scale, and the anxiety subscale of the symptom checklist-90. Moderated mediation analyses were conducted to examine the possible mediating role of alexithymia and moderating role of sex in the associations between parental bonding and depressive/anxiety symptoms.

Results

Alexithymia was found to be a potential mediator and sex be a moderator in the relations between perceived dysfunctional parental bonding and the psychological symptoms. Specifically, dysfunctional paternal bonding, especially paternal overprotection, had stronger indirect effects (via alexithymia) on the psychological symptoms in males.

Conclusions

This study indicates the importance of alexithymia in the parenting-related mental health impacts and highlights the significance of paternal bonding for the development of alexithymia and mental health problems in male populations. The findings improve the limited understanding of sex-related parental factors for alexithymia and mental health problems. Future studies in longitudinal designs are warranted to clarify the causal process of the mediation.     

Role of prenatal diagnosis and counseling in the management of 735 pregnancies complicated by primary human cytomegalovirus infection: A 20-year experience

BackgroundThe burden of congenital human cytomegalovirus (HCMV) infection is well recognized. However, screening for maternal infection remains controversial in view of diagnostic challenges, counseling difficulties, and absence of medical treatment.ObjectiveTo assess the role of prenatal diagnosis and counseling in the management of pregnancy complicated by primary HCMV infection.Study designRetrospective study aimed at investigating diagnostic features, options, and pregnancy outcome in 735 women with primary HCMV infection over a period of 20 years (1990–2009).ResultsOverall, 25.6% women were found to be seronegative before the actual pregnancy. However, none were informed about HCMV infection and potential prevention strategies. Diagnosis of primary HCMV infection was achieved by seroconversion in 44.4% cases and by different combinations of virus-specific IgM, low IgG avidity, and DNAemia in 43.9% cases. Non-specific symptoms and/or haematological/biochemical alterations were recalled by 73.5% women. The onset of infection could be established, and counseling adjusted accordingly in >90% cases. The overall rate of vertical transmission was 37.1%, ranging from 5.6% for preconceptional infections to 64.1% for third trimester infections. Amniocentesis was chosen by 43.1% women, whereas pregnancy termination was requested by 15.6%.ConclusionsReference virology centers and ad hoc trained and experienced physicians are required for accurate diagnosis of primary infection in pregnancy and ensuing counseling. Prenatal diagnosis has a central role in the management of pregnancies complicated by primary HCMV infection. HCMV-seronegative women should receive adequate information.     

Attachment in mental health institutions: A critical review of assumptions,clinical implications,and research strategies

Attachment is relevant to institutionalized treatment and the therapeutic process in three identifiable ways: (1) patients bring their mental representations of previous and existing attachment relationships to the treatment; (2) attachment is relevant to the extent to which a therapeutic alliance is established and maintained, both in terms of the mental representations of attachment in the patient and in the therapist and how these influence interactive behaviour and expectations in each partner to the therapeutic work; (3) the outcome of the treatment may be related to attachment; for example, when institutional experiences have an enduring impact on attachment representations and the future attachment behaviour of the patient. However, this brief review of attachment concepts reveals that several theoretical, conceptual and empirical questions remain to be answered before evidence-based clinical attachment guidelines can be formulated concerning patient-staff relationships.