Objective: Australia's Better Access initiative enables people with mental disorders to be referred for treatment and management through a range of providers. The costs to consumers are offset by Medicare rebates. We examined eligible providers' and referrers' views and experiences with Better Access. Method: An anonymous online survey was completed by 2386 participants: 572 clinical psychologists, 1140 psychologists, 398 social workers, 104 occupational therapists, 45 general practitioners and 126 psychiatrists. The survey included questions about processes, outcomes, barriers and facilitators associated with Better Access. Results: Most survey participants (54-99% depending on professional group) had provided Better Access services in 2021. The majority believed Better Access enables them to deliver care that is appropriate, tailored to consumers' needs and achieves good outcomes. However, there were concerns that consumers who require more intensive or linked-up care might not receive adequate care through Better Access. Many providers, particularly allied health professionals, did not have the capacity to take on new consumers, leading to long waiting lists and delayed treatment. High out-of-pocket costs (a flow-on effect of inadequate rebates) were seen as discouraging engagement by consumers on low incomes. Good communication between referrers and providers was seen as a key facilitator of Better Access care, but complicated referral and review processes were identified as impeding communication and disrupting continuity of care for consumers. Conclusion: Providers and referrers agreed that Better Access achieves good outcomes for consumers. Strategies to address workforce capacity and affordability for consumers, and to streamline referral and review processes are needed.

Objective: This study examined the effectiveness of the Better Access initiative using outcome data from real-world practice settings. Methods: We used anonymised data from four datasets to assess outcomes for consumers over 86,121 episodes of care. The datasets contained routinely captured episode-level data from the practices of psychologists and other eligible Better Access providers. Across the datasets, outcomes were assessed on 11 different measures (mostly consumer-rated measures of depression and anxiety symptoms, psychological distress, functioning and wellbeing). We conducted purpose-designed analyses with three of the datasets (83,346 episodes), examining score changes on given measures between the first and last assessment occasion within an episode. We used preexisting outputs for the fourth dataset (2775 episodes), again considering change from the beginning to the end of the episode. Results: In the purpose-designed analyses, consumers' mental health improved in around 50-60% of episodes. However, consumers showed no change or experienced deterioration in their mental health in 20-30% and 10-20% of episodes, respectively. Those with more severe baseline scores had a greater probability of showing improvement. The preexisting outputs also identified significant improvements, particularly in episodes where treatment was complete. Conclusion: Better Access is achieving reductions in symptoms and improvements in functioning and wellbeing for the majority of consumers. A minority of consumers do not have these sorts of positive outcomes, however, and further work is required to understand why. Routine measurement of outcomes - particularly consumer-rated outcomes - would enable ongoing monitoring of the extent to which Better Access is achieving its goals.

OBJECTIVE:To describe characteristics, service use and clinical changes among people who received treatment through Australia's Better Access programme. METHODS:We re-analysed data from the usual care arms of two randomised controlled trials of tailored care approaches for depression and anxiety in primary care (Target-D, 2016-2019; Link-me, 2017-2019). Participants completed measures of depression and anxiety symptoms, quality of life and days out of role due to psychological distress over 12 months. They reported the use of mental health services from different providers/settings; from this, we classified a subset as likely Better Access treatment users. RESULTS:Of 394 Target-D and 547 Link-me participants, one-third were classified as having used Better Access treatment sessions over 12 months. They used five to seven Better Access sessions on average; half to two-thirds paid out-of-pocket costs (median $78-$89 per session). The number of Better Access sessions and other mental health services they used increased with severity of mental health problems. At baseline, Better Access treatment users reported more severe symptoms and more days out of role than those who used other or no mental health services, and poorer quality of life than those who used no services. Approximately half (43-55%) of Better Access treatment users showed improvements in mental health over 12 months. Among those with severe problems, improvements in depression and anxiety symptoms were associated with using 5+ Better Access sessions. CONCLUSIONS:Better Access treatment is used by people with different levels of mental health need. Many experience improvements in their mental health and functioning.

OBJECTIVE:Australia's Better Access initiative enables Australians with mental disorders to receive sessions of evidence-based psychological treatment following referral from an eligible provider (usually a general practitioner), subsidised through Medicare. As part of a commissioned evaluation, we examined patterns of Better Access treatment. METHODS:We sourced aggregated Medicare Benefits Schedule data from Services Australia on Better Access services delivered from 1 January 2018 to 30 June 2022. From this, we developed profiles of Better Access treatment over time and according to key consumer characteristics. RESULTS:In 2021, over 1.3 million Australians received at least one treatment session subsidised through Better Access (up by 0.9% per year since 2018). People living in medium/high socioeconomic status areas within major cities, females and young adults were more likely to receive Better Access treatment compared to other groups. Consumers made an out-of-pocket payment for two-thirds (64.8%) of treatment sessions in 2021 (vs 52.7% in 2018). The median out-of-pocket payment per session was constant between 2018 and 2021 ($74) but increased to $90 in the first half of 2022. In 2021, 29.9% of fees charged for all treatment sessions nationally came from consumer out-of-pocket payments (vs 24.5% in 2018). Fewer people accessed treatment following referral in 2021 than in 2018 (58.8% vs 66.9%), and those who did waited longer until their first session (median 22 days in 2021 vs 18 days in 2018). CONCLUSION:Better Access enables many Australians to receive psychological treatment. Efforts are required to address gaps in access and increased wait time and consumer costs.

OBJECTIVE:This study aimed to provide a picture of who uses Better Access treatment services, how they do so and what the benefits are. METHODS:We conducted an observational prospective study involving independent cohorts from the Australian Longitudinal Study on Male Health (Ten to Men [TTM]) and the Australian Longitudinal Study of Women's Health (ALSWH). We used data from two pairs of baseline (T0) and follow-up (T1) waves for those aged ⩾ 18 in TTM and those in the 1989-1995, 1973-1978 and 1946-1951 cohorts in ALSWH. Using survey data and linked Medicare Benefits Schedule (MBS) claims data, we identified participants with 'mental health need' at T0 who had and had not used Better Access treatment services between T0 and T1. RESULTS:Proportions of Better Access users varied across study cohorts and analyses, with 45% being the highest. Those who used Better Access treatment services typically accessed 5-6 sessions, usually from clinical psychologists and/or psychologists. Between half and three-quarters paid out-of-pocket costs (usually $80-$100/session). Typically, around half of those who used Better Access had better mental health at T1 than T0. Severity of mental health problems at baseline was strongly predictive of both Better Access use and improvements in mental health. CONCLUSION:Australian adults with mental health need make varying use of Better Access treatment services, but the programme appears to serve those with high levels of need relatively well.

This study investigates the epidemiology of adolescent suicide in India, addressing the limited research on the subject. Data on adolescent suicide (14-17 years) by sex and state were obtained from the National Crimes Records Bureau for 2014-2019, which included acquiring unpublished data from 2016 to 2019. Crude suicide rates for the period 2014-2019 were calculated by sex and state. Rate ratios (RRs) by sex and state were also calculated to assess changes over time, comparing suicide rates from 2017-2019 to 2014-2016. Female adolescent suicide rates, which ranged between 9.04 and 8.10 per 100,000 population, were consistently higher than male adolescent suicide rates, which ranged between 8.47 and 6.24 per 100,000 population. Compared to the first half of the study period (2014-2016), adolescent suicide rates significantly increased between 2017 and 2019 among less developed states (RRs = 1.06, 95% uncertainty interval [UI] = 1.03-1.09) and among females in these states (RRs = 1.09, 95% UI = 1.05-1.14). Male suicide rates aligned with global averages, while female rates were two to six times higher than in high-income and Southeast Asian countries. Findings highlight the urgent need for comprehensive surveillance and targeted suicide prevention strategies to address this critical public health issue.

ObjectivesThis research describes four aspects of the development of the Sense of Safety Theoretical Framework for whole person care: exploring the meaning of the phrase “sense of safety”—the whole person language; the range of human experience that impacts sense of safety—whole person scope; the dynamics that build sense of safety—the healing goals; and the personal and cross-disciplinary trauma-informed practitioner skills and attitudes that facilitate sense of safety.MethodsThis qualitative participatory study was conducted in two phases. Researchers iteratively explored the concept of sense of safety using focus groups and semi-structured interviews. Overarching research questions were: “Does the transdisciplinary concept of Sense of Safety make sense as an approach to the whole person in distress?”; “How do participants describe the meaning of the phrase “sense of safety”?”; “What does a person experience when they feel safe?” and “What can practitioners do to facilitate a sense of safety?” Phase One involved rural and urban family doctors, mental health clinicians across multiple disciplines, people with lived experience of mental distress, and Indigenous Australian academics. Phase Two widened the scope of disciplines involved to iteratively reflect on their clinical and personal experience with “sense of safety” and included international family doctors, physiotherapists, occupational therapists, social workers, teachers, multidisciplinary rural clinicians and multidisciplinary clinicians with a lived experience of physical trauma, grief, and severe mental illness.ResultsThe everyday language “sense of safety” was found to describe a whole person experience that integrates awareness of self, others, and context. The scope of human experience that impacts sensed safety was found to include seven domains: Environment, Social Climate, Relationships, Body, Inner Experience, Sense of Self and Spirit/Meaning (Whole Person Domains). Five dynamic healing goals were identified that build sense of safety: Broad Awareness; Calm Sense-Making; Respectful Connection; Capable Engagement; and Owning Yourself (Sense of Safety Dynamics). Five practitioner skills and attitudes that facilitate sense of safety were named: Valuing the Whole Picture; Holding Story Safely; Being with You; Learning Together; and Validating Dignity (Sense of Safety Practitioner Skills).ConclusionThe Sense of Safety Theoretical Framework developed in this study focusses on an experience that is a fundamental prerequisite of health. Sense of safety is affected by, and influences, life story, relationships, meaning, sense of self, and – physical health: the whole person. The language “sense of safety” communicates an integrative experience that can help clinicians to see the whole person and describe a cross-disciplinary goal of care. The Whole Person Domains clarify the scope of care required, while the Sense of Safety Dynamics offer practical processes of care. The Sense of Safety Practitioner Skills describe trauma-informed skills and attitudes that facilitate a sense of safety. Each of these parts of the Sense of Safety Theoretical Framework translate practitioner, lived experience, and First Nations wisdom and a wide existing transdisciplinary literature into a framework and language ready for practice. Assessing and building sense of safety prioritizes a healing-oriented and trauma-informed approach. The Sense of Safety Theoretical Framework facilitates a paradigm shift that towards integrating sensation, subjective experience, physiology, and social determinants into everyday quality care in health, education and public policy.

AIMS:The aim of the study was to examine the interplay between income inequality, psychological distress, medication use and access to psychologist consultations in Australia. METHODS:Hypothesis-driven secondary data analysis was conducted using nationally representative data from the 2011-2012, 2014-2015 and 2017-2018 Australian National Health Surveys. Approximately 12,000 working-age participants (18-64 years) were analysed per survey year, with subgroup interaction effects (p < 0.1) explored. RESULTS:Overall, 16% of participants reported taking medications, and 5% consulted a psychologist in the past year. About 14% experienced high distress, and 5% had very-high distress in the past month. Lower-income individuals were more likely to experience high psychological distress and use mental health medications. Specifically, 30% of adults in the lowest income quintile used medications, and 14% reported very-high distress, compared to 10% and 2% in the highest income group. More low-income individuals (9%) consulted a psychologist compared to high-income individuals (4%). Interaction analyses revealed that lower-income individuals who used medication or saw a psychologist exhibited up to four times higher distress than those in higher-income groups. CONCLUSIONS:The findings reveal a concerning disparity when combined with other national data: individuals in the lowest income quintile face higher mental health symptoms, greater medication use, and are more likely to consult a psychologist, yet receive fewer consultations. This exploratory work deepens understanding of the complex relationship between income inequality, mental health symptoms, medications and healthcare utilisation in well-resourced countries like Australia. With mental ill-health rising globally, understanding these dynamics is crucial for designing equitable mental health policies.

Internationally, capacity building for mental health implementation and translation research has lagged. A review of literature found initiatives since 2008 indicating limited dedicated attention to growing capabilities of early-to-mid-career mental health researchers, and little reporting of tailored career pathways and skills growth. Significant gaps in capacity building thus exist. This perspective article describes a networked infrastructure for a capacity building strategy of the Australian-based ALIVE National Centre for Mental Health Research Translation. The Centre was funded as a special initiative in mental health with an initial five-year investment. In 2022, the Centre established the first national, cross-disciplinary mental health Next Generation Researcher Network, including a tailored Lived-Experience Research Collective with the aim to grow future research leaders and establish career pathways embedded within the research activities of the Centre. After three years of operation, membership is upward of 280 people in the Next Generation Researcher Network and more than 250 people for the Collective. Specific components implemented as part of the strategy include a central coordination hub, coleadership approaches, coresearch models, tailored traineeships, skills-building through short courses and learning events, cocreation of resources, an online peer discussion platform and annual seed funding schemes. A continuous capacity-building strategy is critical for advancing global research agendas to improve mental health implementation and translation outcomes. Success requires network infrastructure to ensure research methodologies advance, and research addresses the priorities of people most impacted, and early and mid-career researcher capabilities across all research settings connected with universities and service sectors grow.

OBJECTIVE:This study aimed to estimate the proportions of Australians aged 16-85 years who consulted health professionals for mental health in 2020-2022, and changes since 2007. METHODS:Secondary analysis of merged data from the National Study of Mental Health and Wellbeing in 2020-2022 (N = 15,893) and its 2007 predecessor (N = 8841). RESULTS:In 2020-2022, 17.4% of Australians aged 16-85 years had consulted a health professional (including overnight hospital admission) for their mental health in the past year (vs 11.9% in 2007). The largest increases between the surveys were in use of psychologists (123%), other (non-medical) mental health professionals (64%), and general practitioners (53%). Of adults with a 12-month mental disorder, 46.6% consulted a health professional in 2020-2022 (vs 37.5% in 2007), increasing with severity (mild 22.9%, moderate 48.4% and severe 68.8%). Multivariate regression models showed that consulting a health professional was positively associated with age < 65 years, female sex, being unmarried, disorder severity, and affective or anxiety disorder; these patterns held for consultations with most types of professionals. Socioeconomic and geographical characteristics were associated with consulting particular professionals: lower income (consulting a psychiatrist), high income and living in a major city (psychologist), living in a less disadvantaged area (general practitioner). Increases in consulting were not experienced by all groups (e.g. the likelihood of consulting increased for people aged 16-45 years, but not for older age groups). CONCLUSION:Consultation with health professionals for mental health improved between 2007 and 2020-2022 but remains below national targets. Some changes may reflect recent service reforms; however, gaps in access persist.

OBJECTIVE:Mental and substance use disorders are the leading causes of disability worldwide. Contemporary estimates of prevalence, severity and impairment are essential for service planning. This study provides estimates of prevalence, severity, impairment and demographic correlates of mental and substance use disorders in 2020-22 and changes in prevalence since 2007. METHODS:Data were from the two Australian National Surveys of Mental Health and Wellbeing conducted in 2020-22 (N = 15,893) and 2007 (N = 8841). Descriptive statistics report prevalence of lifetime and 12-month mental and substance use disorder by sex and age, proportion of people with each mental disorder by levels of severity (mild, moderate and severe) and mean days out of role by mental disorder class (mood, anxiety, substance use). Logistic regression analyses examined demographic correlates of mental disorder class and assessed changes over time. RESULTS:The lifetime prevalence of any mental or substance use disorder in 2020-22 was 40.2%. The 12-month prevalence was 20.2% (mood disorder - 7.4%, anxiety disorder - 15.7% and substance use disorder - 3.1%). Mood disorders were associated with significant impairment. The prevalence of mental disorders has changed over time, with mood and anxiety disorders increasing and substance use disorders decreasing. These changes were most evident among young adults. CONCLUSION:Mental disorders are common in Australia. Impairment associated with mental disorders remains significant. Particular focus should be paid to young adults aged 16-25 years who have shown the largest increases in anxiety and mood disorder prevalence over the past 13 years.

Previous studies found similarities in adults' disgust responses to benign (e.g. obesity) and actual disease signs (e.g. influenza). However, limited research has compared visual (i.e. benign and actual) to cognitive (i.e. disease label) disease cues in different age groups. The current study investigated disgust responses across middle childhood (7-9 years), late childhood (10-12 years), adolescence (13-17 years), and adulthood (18+ years). Participants viewed individuals representing a benign visual disease (obese), sick-looking (staphylococcus), sick-label (cold/flu), and healthy condition. Disgust-related outcomes were: (1) avoidance, or contact level with apparel the individual was said to have worn, (2) disgust facial reactions, and (3) a combination of (1) and (2). Avoidance was greater for the sick-looking and sick-label than the healthy and obese conditions. For facial reaction and combination outcomes, middle childhood participants responded with greater disgust to the sick-looking than the healthy condition, while late childhood participants expressed stronger disgust towards the sick-looking and obese conditions than the healthy condition. Adolescents and adults exhibited stronger disgust towards sick-label and sick-looking than obese and healthy conditions. Results suggest visual cues are central to children's disgust responses whereas adolescents and adult responses considered cognitive cues.

Objective: This study aimed to describe the epidemiology of suicidal ideation, suicide plans and suicide attempts, examine services received for suicide attempts, and explore the relationship between suicide attempts and self-harm without suicidal intent. Methods: We used survey data from the 2020–2022 National Study of Mental Health and Wellbeing, which involved a nationally representative sample of Australian adults aged 16–85 ( n = 15,893). Comparisons were made with the 2007 National Study of Mental Health and Wellbeing ( n = 8841). Results: In 2020–2022, the proportions of adults who had experienced suicidal ideation, suicide plans and suicide attempts during their lifetime were 16.6%, 7.5% and 4.9%, respectively. The proportions who had experienced these in the past 12 months were 3.3%, 1.1% and 0.3%. The odds of experiencing suicidal ideation and making a suicide plan were significantly higher in 2020–2022 than in 2007. Groups at heightened risk of suicidal ideation, suicide plans and/or suicide attempts in the previous 12 months were males, young people, people who were gay, lesbian, or bisexual or used some other term to describe their sexual identity, people outside the labour force, people from disadvantaged areas and people with mental disorders. Two-fifths of those who attempted suicide during the previous 12 months did not use health services following their attempt, and two-thirds also self-harmed without suicidal intent. Conclusion: The implications of these findings for the forthcoming National Suicide Prevention Strategy are discussed. Suicidal thoughts and behaviours confer risk for suicide and are significant problems in their own right. Their prevention requires a strong whole-of-government response.

The objective of this chapter is to present the rationale for data preparation and practical guidance for conducting the procedures in applied research. It is argued that the scope of data preparation is far greater than the application of now classic diagnostic procedures such as those outlined for the regression family. Data preparation presents an opportunity to assess the integrity of the dataset and to make any necessary consequent adjustments to either the data or the analytic plan. A series of questions are outlined that provoke scrutiny of the data, followed by a set of pre-analysis procedures that help to identify any early issues. Next, the classic regression diagnostics are presented as an example of the assessment of model adequacy in the analysis stage. Finally, a brief guide is presented to the logic and creation of dummy variables, which are important tools to deal with potentially problematic situations, both expected and novel.

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an intensive but effective treatment for malignant and non-malignant diseases. However, long-term survival often comes at a cost, with survivors experiencing chronic morbidity and are at risk of relapse and secondary malignancy. This study aimed to describe decisional regret in a large cohort of Australian long-term allo-HSCT survivors. A cross-sectional survey was conducted with 441 adults in New South Wales, assessing quality of life (QoL), psychological, social, demographic, and clinical variables. Less than 10% of survivors expressed regret, with chronic graft-versus-host disease being the most important clinical factor. Psycho-socioeconomic factors such as depression, lower QoL scores, lower household income, higher treatment burden, and not resuming sex post-HSCT were also associated with regret. Findings highlight the need for valid informed consent and ongoing follow-up and support for allo-HSCT survivors dealing with life post-transplant. Nurses and healthcare professionals play a critical role in addressing decisional regret in these patients.

AimsGiven the increasing number of Hematopoietic Stem Cell Transplantations (HSCT) performed world-wide, the increasing likelihood of survival following HSCT, and the profound physical, psychosocial, and emotional impact of HSCT on survivors, their carers and families, it is important to identify factors that may contribute to or support post-traumatic growth (PTG) after transplant. In this study, we aimed to investigate the prevalence of PTG in an Australian cohort of long-term allogeneic HSCT survivors and describe associations between PTG and relevant clinical, sociodemographic and psychological variables.MethodsThis was a large, multi-centre, cross sectional survey of Australian HSCT-survivors inviting all those transplanted in New South Wales between 2000 and 2012. Respondents completed the PTG Inventory (PTGI), the Sydney Post-BMT Survey, FACT-BMT, DASS 21, The Chronic Graft versus Host Disease (GVHD) Activity Assessment-Patient Self-Report (Form B), the Lee Chronic GVHD Symptom Scale, and the Fear of Cancer Recurrence Scale. Data was analysed using independent t-tests, one-way analysis of variance, and pearson's correlations, and hierarchical multiple regression adjusted for potential confounders and to ascertain independent associations of explanatory variables with PTG.ResultsOf 441 respondents, 99% reported some level of PTG with 67% reporting moderate to high levels of PTG. Female gender, younger age, complementary therapy use, anxiety, psychological distress and psychosocial care, and higher quality of life were associated with higher levels of PTG. Importantly, we also found that PTG was not associated with either chronic GVHD or post-HSCT morbidity.ConclusionsIn this study - the largest study of PTG in long-term allogeneic HSCT survivors - we found that growth appears ubiquitous, with 99% of survivors reporting some degree of PTG and 67% reporting moderate-high levels of PTG. Importantly, we found no association with GVHD or chronic physical post-HSCT morbidity, or adverse financial, occupational or sexual impacts. This suggests that it is the necessity for and experience of, HSCT itself that foments personal growth. Accordingly, healthcare professionals should be alert to the profound and wide-ranging impact of HSCT - and the degree to which survivor's may experience PTG. Identifying interventions that may assist HSCT survivors cope and building their resilience is of utmost importance.

BACKGROUND:Restricting access to suicide methods is one of the most effective suicide prevention approaches.METHODS:Trends in method specific suicide rates (2014-2021) in India were calculated using National Crime Records Bureau data (NCRB) by sex and geographical region. Joinpoint regression analysis was used to empirically identify any changes in suicide trends.RESULTS:Suicide rates by hanging increased from 6.08 to 10.0 per 100,000 population among males and from 2.55 to 3.56 per 100,000 among females over the study period. Insecticide poisoning suicide rates also increased from 1.51 to 2.73 per 100,000 among males and from 0.74 to 1.14 per 100,000 among females. Suicide by self-immolation decreased over the study period among both sexes. In general, these national trends were mirrored among different regions. Joinpoint regression indicated an increase in suicide by hanging (annual percentage change (APC) of 12.3 among males between 2018 and 2021 and 4.9 among females between 2014 and 2021) and an increase in male suicide by insecticide poisoning between 2014 and 2021 (APC of 4.2) while a decrease in self-immolation rates was noted among males (APC of -12.7 between 2014 and 2021) and females (APC of -16.5 between 2016 and 2021).LIMITATION:The NCRB data might underestimate true suicide rates.CONCLUSION:Hanging suicides and insecticides poisoning suicides observed an increasing trend between 2014 and 2021. Self-immolation rates decreased during the study period which might be, in part, associated with the initiative to provide clean cooking fuel to households. Ban on lethal pesticides must be prioritised which might help lower insecticide poisoning suicide rates.

Aims and method Recently, the Health of the Nation Outcome Scales 65+ (HoNOS65+) were revised. Twenty-five experts from Australia and New Zealand completed an anonymous web-based survey about the content validity of the revised measure, the HoNOS Older Adults (HoNOS OA). Results All 12 HoNOS OA scales were rated by most (≥75%) experts as ‘important’ or ‘very important’ for determining overall clinical severity among older adults. Ratings of sensitivity to change, comprehensibility and comprehensiveness were more variable, but mostly positive. Experts’ comments provided possible explanations. For example, some experts suggested modifying or expanding the glossary examples for some scales (e.g. those measuring problems with relationships and problems with activities of daily living) to be more older adult-specific. Clinical implications Experts agreed that the HoNOS OA measures important constructs. Training may need to orient experienced raters to the rationale for some revisions. Further psychometric testing of the HoNOS OA is recommended.

We aimed to determine (1) the attributes of multiple stigmatized populations, (2) whether Kurzban and Leary's (2001) functional typology of stigma emerges and identifies the dimensions upon which each stigma type differs, and (3) the emotional responses toward emergent stigma types. Participants (N = 2,674) were assigned to 1/52 stigma target conditions and their attitudes surveyed. Data were analyzed by multilevel factor analysis with stigma targets at Level 2. There were five within-factors at Level 1 (social competence, interpersonal access, social inclusion, immorality, perceived permanence) and three between-factors at Level 2 (interpersonal stigmatization, morality-based stigmatization, chronic stigmatization). Interpersonal stigmatization was predicted by disgust and pity, and morality-based stigmatization was predicted by disgust and [-]happiness, with no predictors for chronic stigmatization. These results support a functional typology of stigma.