Stigma toward individuals with alcohol use disorders is widespread and contributes to negative consequences for those affected. Health care professionals may share the public's stigmatizing attitudes, and this may impede effective care. In China, the use of involuntary treatment and detention for substance use disorders remains prevalent and concerning. However, limited empirical research has examined how health care professionals' prejudices impact their endorsement of segregation and coercion. This cross-sectional study surveyed 492 health care professionals from diverse disciplines across 31 province-level regions in Mainland China. Participants completed validated measures assessing perceived stigma, attributions of dangerousness, controllability and personal responsibility, emotional reactions, helping and avoidant behaviors, and the endorsement of segregation and coercion (analyzed jointly as a single construct in this study). Higher levels of perceived stigma, controllability, and dangerousness were directly associated with increased endorsement of segregation-coercion and were also significantly indirectly mediated by the attribution of personal responsibility (beta = 0.02, beta = 0.06, and beta = 0.02, respectively), controlling for age, gender, years of work experience, mental health background, and alcohol consumption. A higher perceived controllability was linked to both increased helping and avoidance behaviors, which in turn were associated with the endorsement of segregation-coercion. The model showed good fit (CFI = 0.99, RMSE = 0.03) and explained 64% of the variance in segregation-coercion. Findings underscore the need for antistigma programs that promote nonblaming attitudes and respectful care. Policymakers should enact and enforce policies to mitigate public stigma associated with alcohol use disorders and foster nonstigmatizing practices in health care settings.

BackgroundInterventions to reduce public suicide stigma (i.e. negative attitudes towards persons affected by suicide/suicidality) could contribute to suicide prevention. However, such interventions could unintentionally increase suicide normalization (i.e. liberal attitudes towards suicide) and therefore increase suicide risk. We aimed to test the efficacy of education- and contact-based interventions delivered online via video or text on both public suicide stigma and suicide normalization.MethodsWe conducted a web-based randomized controlled trial among N = 2,043 participants recruited from an established online research panel. Participants were randomized into six groups, receiving either one of four contact- or education-based interventions that were transferred via text or video (contact text, contact video, education text, education video) or control group content (contact control, education control). Information about suicide stigma and suicide normalization were collected directly before (t0) and after intervention participation (t1) as well as about two weeks later (t2). To explore the attractiveness of the provided intervention material, we used Brown-Mood's median test to compare the times participants spent with the provided intervention material in each group. We then used linear mixed models to compare effects on suicide stigma and suicide normalization between intervention groups and control groups.ResultsMedian times spent with provided material were generally longer among participants exposed to video material than among participants exposed to text material, and among participants in contact-based interventions than among participants in education-based interventions. We did not observe stronger effects in intervention groups compared to control groups on suicide stigma or suicide normalization. Surprisingly, suicide stigma and suicide normalization appeared to decrease from t0 to t1 in both intervention and control groups.ConclusionOur findings suggest a higher attractiveness of video- and contact-based material compared to text- and education-based material. However, none of the interventions had a significant effect on public suicide stigma or suicide normalization. Future research should explore innovative and safe approaches to reduce public suicide stigma. Experimental studies may focus on interventions with higher attractiveness (i.e. video and contact-based interventions), use interventions with higher intensity (i.e. longer interventions, more repetitions), and assess suicide stigma with implicit measures to avoid response bias.Trial registrationThe RCT was registered at clinicaltrials.gov on February 11th, 2021 (NCT04756219).

BackgroundUnemployment is a risk factor for the development and perpetuation of psychological distress. Finding support for affected individuals can be particularly challenging, which causes a vicious cycle of psychological distress and unemployment. ObjectiveThe aim of this systematic review is to assess and summarize existing evidence regarding interventions that address both mental health and re-employment, emphasizing accessibility through community or social care structures. MethodsA systematic literature search using PubMed and EBSCOhost and an additional search using reference list screening were conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In order to identify interventions for the mental health and re-employment of individuals experiencing psychological distress and unemployment, an inclusion process according to the PICO (population, intervention, comparison, and outcome) scheme and the study design was applied. Title and abstract screening and full-text screening for eligibility were performed independently by 2 reviewers. Quality assessments using the Cochrane Risk of Bias Tools for randomized and nonrandomized trials were conducted by 2 independent reviewers. ResultsThe initial systematic search yielded 4442 results, and 15 articles were additionally identified via reference list screening. Eventually, 74 articles were subjected to a thorough evaluation process by 2 independent reviewers. The interrater reliability was determined to be good, with a Cohen κ score of 0.770. After a multistep extraction process, 17 studies remained for inclusion, with each focusing on the improvement of mental health, re-employment, or both outcomes. A heterogeneous pattern of results emerged, with most interventions showing improvement in either mental health or re-employment. Most studies were assessed as having a moderate (n=7) or high (n=9) risk of bias. ConclusionsThe results of the systematic research indicate that low-threshold services in close cooperation with institutions and exchange with other supportive stakeholders should be fostered. Derivable overarching themes and intervention content for integrative support measures can serve as guidelines for future interventions. Trial RegistrationPROSPERO CRD42022378490; https://www.crd.york.ac.uk/PROSPERO/view/CRD42022378490

Purpose Research from Western societies indicates pervasive public stigma against people with alcohol use disorders (AUDs). However, there is a lack of knowledge about the interactions between different components of stigma and their contribution to discriminatory behaviour towards individuals with AUDs within the Chinese cultural context. The aim of the present study was therefore to investigate the relationships of (mis-)conceptions, stereotypes, emotional reactions, perceived public stigma and their contribution to the desire for social distance among the Chinese adults. Methods (Mis-)conceptions, stereotypes, emotional responses, willingness to help and avoid, perceived stigma, and the desire for social distance from individuals with AUDs were assessed via a cross-sectional online survey with a sample of 1,100 adults from the Chinese population. Results Three-fourth of the participants recognised AUDs as mental illnesses, though 70% of the sample did not support health insurance coverage for the treatment of AUDs. A stronger desire for social distance was associated with greater recognition of alcohol use disorders as mental illnesses, heightened perceptions of dangerousness and personal responsibility, increased fear, and more willingness to avoid and withhold help, controlling for age, gender, education, employment, mental health service utilisation, and alcohol consumption. Fear fully mediated the effects of perceptions of dangerousness and responsibility on the desire for social distance. Conclusions To improve social integration for individuals with AUDs in China, culturally tailored anti-stigma programmes are needed to reduce negative attitudes and discriminatory behaviours among the Chinese population.

How are stigma processes refl ected in policies that impact migrants?How might policies that impact migrants amplify and/or mitigate stigma processes for migrants?This chapter explores the role of policy narratives and frameworks (e.g., assimilation, integration, multiculturalism) in shaping specifi c policy types (e.g., targeted, universal, mainstream) that diff erentially conceptualize and aff ect the roles, rights, and opportunities of migrants in society.The complexity of the policy-making process is examined, including the specifi c policy context and political discourse, trade-off s leading to a mix of policy types, competing policies across jurisdictions (e.g., international, federal, regional), and diff erential implementation of policies.Throughout, policies are considered that can intentionally or unintentionally generate, amplify, and/or mitigate stigma processes.In addition, this chapter examines consequences of these policy-generated stigma experiences for both migrants and nonmigrants, the feedback processes from these stigma experiences to the demand for policy change, and strategies to improve policy making with specifi c consideration for stigma in the context of migration-generated diversity.Empirical gaps in the literature are noted and recommendations are made to address these knowledge gaps.

BACKGROUND:There is a vicious cycle between unemployment and mental health issues. Unemployed individuals with mental health issues require individualized support at multiple levels in order to promote their mental health, and obtain and retain employment. The 3for1-intervention program aims to provide such support with three components (short-term psychotherapy, job coaching based on the Individual Placement and Support approach, and peer support). This study protocol outlines how the effectiveness of this three-component intervention program in terms of re-employment, mental health, and psychosocial outcomes will be evaluated. METHODS:The 3for1-intervention program will be evaluated with a non-randomized controlled trial design in a multi-center study. 500 eligible participants aged between 18 and 60 years from six job centers in Southern Germany will be allocated to a control group or an intervention group. Allocation is time-based, with the control group being recruited first, followed by recruitment of the intervention group. The control group will receive treatment as usual, whereas the intervention group will receive treatment as usual as well as access to the three intervention components over a period of 12 months. Assessment will be conducted at baseline (t0), and 12 (t1) and 18 (t3) months later. The primary outcome will be the proportion of participants who are in employment subject to social insurance contributions at t1. Differences between control and intervention group will be tested with logistic regression analysis, controlling for relevant covariates. Analyses of secondary outcomes will relate to group differences regarding re-employment, health and well-being, social integration, help-seeking, and self-stigma at t1 and t2, applying logistic regression analysis or analysis of covariance. Additionally, usage of health services will be measured to evaluate the intervention program's cost effectiveness. DISCUSSION:The 3for1-intervention aims to improve employability and mental health outcomes of a vulnerable population with high need for assistance. Improvements for this population would benefit the German welfare state as well. This study could provide valuable insights into the feasibility, implementation, and sustainability of this individualized, multi-level support program within German job centers. TRIAL REGISTRATION:This trial is registered with the German Clinical Trials Register: DRKS00029002 (registered on 11 May 2022).

Abstract Purpose COVID-19 and the resulting restrictions in daily living had society-wide impact on mental health, especially for people with mental disorders. So far, there is little evidence on how the pandemic impacted mental health care provision and perceived access to mental health care. Methods We present self-reported data on mental health and mental health service use comparing pre- and peri-pandemic conditions. Data was taken from an online survey promoted via leaflet and mailing lists with n = 189 individuals who at the time of the survey or before used mental health services. Responses were obtained between mid-July 2021 and mid-June 2022. Results Respondents were on average 34 years old, 83% were women, and the majority were university students. 38% of respondents regarded their mental illness as severe or very severe. Mental distress increased during the pandemic but returned to baseline after the end of the lockdown measures. One third (32%) of participants said that they delayed (26%) or avoided (6%) mental health treatment; 60% responded that access was restricted due to pandemic-related regulations. Conclusion People with mental disorders suffered from decreased mental health during the pandemic. At the same time, they perceived restrictions in mental health care provision and tended to delay mental health treatment due to the COVID-19-related restrictions. This may result in a higher burden of disease following the pandemic. Trial registration The study that this research is a part of is registered with ClinicalTrials.gov: NCT04336527, April 7, 2020, updated May 31, 2023, https://clinicaltrials.gov/ct2/show/NCT04336527.

There is increasing attention to the impacts of stigma and discrimination related to mental health on quality of life and access to and quality of healthcare. Effective strategies for stigma reduction exist, but most evidence comes from high-income settings. Recent reviews of stigma research have identified gaps in the field, including limited cultural and contextual adaptation of interventions, a lack of contextual psychometric information on evaluation tools, and, most notably, a lack of multi-level strategies for stigma reduction. The Indigo Partnership research programme will address these knowledge gaps through a multi-country, multi-site collaboration for anti-stigma interventions in low- and middle-income countries (LMICs) (China, Ethiopia, India, Nepal, and Tunisia). The Indigo Partnership aims to: (1) carry out research to strengthen the understanding of mechanisms of stigma processes and reduce stigma and discrimination against people with mental health conditions in LMICs; and (2) establish a strong collaborative research consortium through the conduct of this programme. Specifically, the Indigo Partnership involves developing and pilot testing anti-stigma interventions at the community, primary care, and mental health specialist care levels, with a systematic approach to cultural and contextual adaptation across the sites. This work also involves transcultural translation and adaptation of stigma and discrimination measurement tools. The Indigo Partnership operates with the key principle of partnering with people with lived experience of mental health conditions for the development and implementation of the pilot interventions, as well as capacity building and cross-site learning to actively develop a more globally representative and equitable mental health research community. This work is envisioned to have a long-lasting impact, both in terms of the capacity building provided to participating institutions and researchers, and the foundation it provides for future research to extend the evidence base of what works to reduce and ultimately end stigma and discrimination in mental health.

PURPOSE:Many people with mental illness experience self-stigma and stigma-related stress and struggle with decisions whether to disclose their condition to others. The peer-led Honest, Open, Proud (HOP) group program supports them in their disclosure decisions. In randomized controlled trials, HOP has shown positive effects on self-stigma and stigma stress on average. This study examined individual predictors of HOP outcomes and tested the hypothesis that stigma stress reduction at the end of HOP mediates positive HOP effects at follow-up.METHODS:Six RCTs were included with data at baseline, post (after the HOP program) and at 3- or 4-week follow-up. Baseline variables were entered in meta-regression models to predict change in self-stigma, stigma stress, depressive symptoms and quality of life among HOP participants. Mediation models examined change in stigma stress (post) as a mediator of HOP effects on self-stigma, depressive symptoms, and quality of life at follow-up.RESULTS:More shame at baseline, and for some outcomes reduced empowerment, predicted reduced HOP effects on stigma stress, self-stigma, depressive symptoms, and quality of life. Younger age was related to greater improvements in stigma stress after the HOP program. Stigma stress reductions at the end of HOP mediated positive effects on self-stigma, depressive symptoms and quality of life at follow-up.CONCLUSION:Participants who are initially less burdened by shame may benefit more from HOP. Stigma stress reduction could be a key mechanism of change that mediates effects on more distal outcomes. Implications for the further development of HOP are discussed.

Background: Suicide loss is often concealed. While initial evidence suggests that disclosure is important for healthy grieving, observed beneficial effects may depend on social reactions. Aim: The current study aimed to identify social reactions and associated consequences experienced by persons who lost a loved one to suicide (i.e., suicide loss survivors). Method: We conducted qualitative interviews with 22 female adult suicide loss survivors focusing on social reactions after suicide loss. Interviews were transcribed and analyzed using qualitative content analysis. Results: When talking about their loss with others, suicide loss survivors experienced a broad range of social reactions including compassionate and supportive responses, speechlessness and insecurity, curiosity and gossip, stigmatization, and grieving expectations. Depending on these social reactions, disclosing suicide loss was associated with both negative and positive long-term effects. Limitations: The findings are limited to the current female sample. Conclusion: Interventions that help suicide loss survivors in finding supportive confidants, combined with public interventions to decrease public suicide stigma and improve the public's readiness to provide helpful support to suicide loss survivors, could improve grieving outcomes among this group.

AIM:To evaluate the psychometric properties of the DISCUS (DISC-Ultra Short), a measure which assesses experienced discrimination among persons with mental disorders.METHODS:Data collected in the three Italian sites (Brescia, Napoli, and Verona) participating at the international project INDIGO-DISCUS. Each Italian site recruited a sample of 50 individuals. Participants were evaluated with the DISCUS. This study evaluated: (a) reliability (internal consistency), (b) validity (convergent and divergent), (c) precision, and (d) acceptability. Participants were also asked to complete three additional measures: Stigma Consciousness, Brief Stigma Coping/Stigma Stress, and Internalized Stigma of Mental Illness (ISMI-10).RESULTS:Overall, 149 people participated; 55% were males, with mean age of 48 (±12.4) years and on average participants had 12 (±3.4) years of education; only 23% were employed. Internal consistency was found to be good (Cronbach α=0.79). Convergent validity was confirmed (all correlations between DISCUS score and the other measures' scores were greater than 0.30). There was evidence of divergent validity, as the overall DISCUS score was not associated with the variable "sex". Precision showed a high correlation coefficient between the various items and the overall DISCUS score, with only one exception (discrimination when looking for housing), which showed a particularly high frequency of "not applicable" responses. Acceptability [measured with Maximum Endorsement Frequencies (MEF) and Aggregate adjacent Endorsement Frequencies (AEF)] was found to be fair (MEF violated in 2 items; AEF partially violated in 5 item).CONCLUSIONS:The Italian version of the DISCUS is a reliable, valid, precise, and acceptable measure of experienced discrimination to be used in large scale studies in the evaluation of anti-stigma initiatives in Italy.

Abstract Purpose COVID-19 and the resulting restrictions in daily living had society-wide impact on mental health, especially for people with mental disorders. So far, there is little evidence on how the pandemic impacted mental health care provision and perceived access to mental health care. Methods We present self-reported data on mental health and mental health service use comparing pre- and peri-pandemic conditions. Data was taken from an online survey promoted via leaflet and mailing lists with n = 189 individuals who at the time of the survey or before used mental health services. Responses were obtained between mid-July 2021 and mid-June 2022. Results Respondents were on average 34 years old, 83% were women, and the majority were university students. 38% of respondents regarded their mental illness as severe or very severe. Mental distress increased during the pandemic but returned to baseline after the end of the lockdown measures. One third (32%) of participants said that they delayed (26%) or avoided (6%) mental health treatment; 60% responded that access was restricted due to pandemic-related regulations. Conclusion People with mental disorders suffered from decreased mental health during the pandemic. At the same time, they perceived restrictions in mental health care provision and tended to delay mental health treatment due to the COVID-19-related restrictions. This may result in a higher burden of disease following the pandemic. Trial registration The study that this research is a part of is registered with ClinicalTrials.gov: NCT04336527, April 7, 2020, updated May 31, 2023, https://clinicaltrials.gov/ct2/show/NCT04336527.

AbstractBackgroundThe Discrimination and Stigma Scale (DISC) is a patient-reported outcome measure which assesses experiences of discrimination among persons with a mental illness globally.MethodsThis study evaluated whether the psychometric properties of a short-form version, DISC-Ultra Short (DISCUS) (11-item), could be replicated in a sample of people with a wide range of mental disorders from 21 sites in 15 countries/territories, across six global regions. The frequency of experienced discrimination was reported. Scaling assumptions (confirmatory factor analysis, inter-item and item-total correlations), reliability (internal consistency) and validity (convergent validity, known groups method) were investigated in each region, and by diagnosis group.Results1195 people participated. The most frequently reported experiences of discrimination were being shunned or avoided at work (48.7%) and discrimination in making or keeping friends (47.2%). Confirmatory factor analysis supported a unidimensional model across all six regions and five diagnosis groups. Convergent validity was confirmed in the total sample and within all regions [ Internalised Stigma of Mental Illness (ISMI-10): 0.28–0.67, stopping self: 0.54–0.72, stigma consciousness: −0.32–0.57], as was internal consistency reliability (α = 0.74–0.84). Known groups validity was established in the global sample with levels of experienced discrimination significantly higher for those experiencing higher depression [Patient Health Questionnaire (PHQ)-2: p < 0.001], lower mental wellbeing [Warwick-Edinburgh Well-being Scale (WEMWBS): p < 0.001], higher suicidal ideation [Beck Hopelessness Scale (BHS)-4: p < 0.001] and higher risk of suicidal behaviour [Suicidal Ideation Attributes Scale (SIDAS): p < 0.001].ConclusionsThe DISCUS is a reliable and valid unidimensional measure of experienced discrimination for use in global settings with similar properties to the longer DISC. It offers a brief assessment of experienced discrimination for use in clinical and research settings.

Background: People who lost a loved one to suicide (i.e., suicide loss survivors, SLS) often struggle to talk about their experiences. However, previous studies suggest beneficial effects of disclosure among this group. Aims: This study aimed to identify determinants of disclosing suicide loss. Method: We conducted qualitative interviews with 22 female SLS focusing on determinants of disclosing suicide loss. Interviews were transcribed and analyzed using qualitative content analysis. Results: We identified contextual factors, perceived risks, and perceived benefits as determinants of disclosing suicide loss. Contextual factors included social settings and characteristics of conversation partners. Perceived risks included emotional distress among oneself and others as well as stigma-related risks of disclosing. Perceived benefits included participants' desire for authenticity and social support, as well as positive effects for grieving and fighting suicide stigma. Limitations: Findings are limited to the current female sample. Conclusion: SLS need support in identifying safe places for disclosure and in developing coping strategies to deal with suicide stigma and emotional distress experienced by themselves and others. Future research should investigate the general public's ability and attitudes to provide support after suicide loss and investigate disclosure decisions among male SLS.

Background Home treatment (HT) is a treatment modality for patients with severe mental illness (SMI) in acute mental crises. It is frequently considered equivalent to psychiatric inpatient treatment in terms of treatment outcome. Peer Support (PS) means that people with lived experience of a mental illness are trained to support others on their way towards recovery. While PS is growing in international importance and despite a growing number of studies supporting its benefits, it is still not comprehensively implemented into routine care. The HoPe (Home Treatment with Peer Support) study investigates a combination of both – HT and PS – to provide further evidence for a recovery-oriented treatment of psychiatric patients. Methods In our randomized controlled trial (RCT), HT with PS is compared with HT without PS within a network of eight psychiatric clinical centers from the North, South and East of Germany. We investigate the effects of a combination of both approaches with respect to the prevention of relapse/recurrence defined as first hospitalization after randomization (primary outcome), disease severity, general functioning, self-efficacy, psychosocial health, stigma resistance, recovery support, and service satisfaction (secondary outcomes). A sample of 286 patients will be assessed at baseline after admission to HT care (data point t 0 ) and randomized into the intervention (HT + PS) and control arm (HT). Follow-Up assessments will be conducted 2, 6 and 12 months after admission (resulting in three further data points, t 1 to t 3 ) and will be analyzed via intention-to-treat approach. Discussion This study may determine the positive effects of PS added to HT, prove additional evidence for the efficacy of PS and thereby facilitate its further implementation into psychiatric settings. The aim is to improve quality of mental health care and patients’ recovery as well as to reduce the risk of relapses and hospitalizations for patients with SMI. Trial registration The trial is registered with ClinicalTrials.gov: NCT04336527 , April 7, 2020.

Over the past few years there have been considerable changes in China's mental health service system. This review provides an overview of the development of mental health services in China, including epidemiological data on psychiatric disorders, utilisation of mental health services, models of mental health service delivery, mental health resources and workforce, mental health policy framework and financial issues. We consider cultural and social factors including the involvement of family members in patient care, urbanisation and internal migration as well as the application of traditional Chinese medicine, which provides implications for mental health research and practice. Additionally, we also discuss major challenges and conclude by providing some specific recommendations on improving mental health services in China.

Purpose Disclosure of mental illness to a supervisor can have positive (e.g. supervisor support) and negative consequences (e.g. stigma). However, research on the association between disclosure and sustainable employability and well-being at work is scarce. The aim of this study was to investigate the association between the disclosure decision (yes/no), experiences with the decision (positive/negative) and sustainable employment and well-being at work among military personnel with mental illness (N = 323). Methods A cross-sectional questionnaire study was conducted. Descriptive and regression (linear and ordinal) analyses were performed. Comparisons were made between those with positive and negative disclosure experiences. Results Disclosure decision (yes/no) was not significantly associated with any of the measures of sustainable employability and well-being at work. However, positive disclosure experiences were significantly associated with higher scores on almost all measures of sustainable employability and well-being at work. Those with negative disclosure experiences reported significantly more shame (Mpos = 2.42, Mneg = 2.78, p < .05) and discrimination (Mpos = 1.70, Mneg = 2.84, p < .001). Those with a positive disclosure experience, reported significantly more supervisor support (Mpos = 3.20, Mneg = 1.94, p < .001). Conclusion We did not find evidence that the disclosure decision itself is related to measures of sustainable employment and well-being at work. In contrast, how participants had experienced their (non-)disclosure decision was significantly related to almost all measures. This emphasizes the importance of the work environments reactions to disclosure and mental illness in the workplace. Future research and interventions should focus on increasing the likelihood of positive disclosure experiences through creating a more inclusive work environment, with more supervisor support and less stigma.