Stigmatising attitudes towards people experiencing mental illness are responsible for substantial additional distress, a reluctance to seek appropriate help (if that help is even available), as well as reduced employment and social opportunities. It turns out that if large portions of society hold negative beliefs about a group that aren’t true, that group suffers. I’ll wait for you to have a lie down through lack of surprise.

While the stereotypes that fuel it may differ, stigma is not focused on one particular diagnosis, but across essentially the entire spectrum of potential causes of mental distress. People with schizophrenia, mood disorders, anxiety disorders and eating disorders can all experience stigma and its negative consequences.

Anti-stigma programs: are they informed by high quality evidence?

There is some acknowledgement from governments, policy makers and other organisations of stigma against mental illness as a significant public health problem. From this follows an acknowledgement of the need to do something about it. Enter the anti-stigma program. However well-meant, it is vital that such anti-stigma programs are informed by high quality research evidence.

Put simply, it is important that we know that anti-stigma programs do what they say on the anti-stigma tin. Even if “anti-stigma tin” sounds like some sort of specialist eye drop.

Types of anti-stigma interventions

The purpose of this recent meta-analysis was to investigate the effectiveness of different types of anti-stigma interventions. Such interventions included:

• Education (teaching people that stigma is bad)
• Consumer contact (introducing people to other people to show them their stigmatising attitudes are wrong)
• Cognitive behaviour therapy (talking to people in a special organised way with homework so that their stigmatising attitudes change)

The interventions didn’t necessarily look at just one type of mental illness stigma and their reduction.

Types of stigma

Types of stigma targeted included:

• Personal stigma (people’s personal beliefs about mental illness)
• Perceived stigma (beliefs people with mental illness have about the beliefs others have about them)
• Internalised stigma (when people with mental illness believe the negative beliefs others have about mental illness are true)

It certainly seems like that stigma and stigma reduction would benefit from a systematic examination!

Methods

Three databases (PubMed, PsycINFO and Cochrane) were searched for potentially relevant abstracts published prior to November 2012 using a variety of appropriate search terms.

A total of 8,246 records were retrieved from the initial search. Once duplicates were removed, the remaining study titles and abstracts were screened in order to remove research irrelevant to the review at hand. The remaining abstracts were coded as relevant or not relevant according to a number of exclusion criteria.

Studies were excluded if they:

• Did not explicitly report change in stigma
• Failed to report stigma data
• Reported the correlates of stigma, but not the effect of interventions to reduce stigma
• Included participants diagnosed with a co-morbid physical condition
• Were concerned only with scale development or measurement
• Addressed stigma associated with factors other than mental illness
• Involved a carer or parent survey in which the respondents answered on behalf of the person in their care

Separate meta-analyses were performed for personal stigma and perceived stigma, considering all studies for which the size of the intervention effect could be estimated. Meta-analyses were also undertaken for a number of different types of study e.g. all educational interventions targeting personal stigma associated with depression, where there were at least two studies in that study subset.

Results

Studies

• Overall, 33 trials were identified. A substantial minority of these trials used more than one type of stigma outcome and several targeted stigma associated with more than one type of mental illness diagnosis
• The greatest research focus was on personal/public stigma (18 studies), followed by perceived stigma, with few studies targeting self-stigma outcomes
• The most common type of intervention involved education
  • All but three of the 18 trials targeting personal/public stigma incorporated anti-stigma education alone or education in combination with another type of anti-stigma intervention
• The next most common intervention was consumer contact

Groups

• Groups receiving the anti-stigma interventions included, in order of frequency:
  • Tertiary students
  • Consumers
  • School students
  • Members of the defence forces
  • The general community
  • Workplace employees
  • Teachers
  • General health professionals
  • Mental health professionals
  • Rural population
  • People from a non-English speaking background
  • Elite athletes

Personal stigma

• In general, the interventions were effective in reducing personal stigma
• There was evidence that interventions incorporating education or a consumer contact component were effective
• There was no evidence that cognitive behaviour therapy significantly reduced stigma (although this was based on only two studies)
• There was no statistically significant difference between the effectiveness of interventions delivered over the internet or not over the internet

Perceived stigma

• Unfortunately, the interventions did not significantly reduce perceived stigma

Internalised stigma

• Two of the trials employed measures focussing on general mental illness and a third focused on schizophrenia
• Both studies involved a type of psychotherapy intervention e.g. cognitive behaviour therapy, cognitive restructuring, or acceptance and commitment therapy
• The effect of these interventions on internalised stigma was non-significant

Mental illness

• There was evidence that interventions designed to reduce the stigma associated with depression specifically were effective
• Interventions in studies employing a generic mental illness or mental health stigma measure were also effective, as were the interventions which targeted psychosis or schizophrenia

Limitations

It would seem that anti-stigma intervention research has largely neglected mental illness diagnoses other than depression or schizophrenia. Only one of the published studies included targeted stigma against generalised anxiety disorder, two focused on substance abuse and no there were no studies targeting bipolar disorder, panic disorder, social anxiety, post-traumatic stress disorder, eating disorders, well, the list goes on. The spectrum of mental distress is a large and varied one and it is not known whether stigma against it is similarly varied. Further research is required to evaluate the stigma associated with specific diagnoses across the range of mental distress and whether stigma reduction is most effective when targeted towards a specific diagnosis or across mental illness stigma in general.

The study found that interventions seemed to reduce personal stigma, but had no effect on perceived stigma or internalised stigma. However, perceived stigma and internalised stigma are largely reactions to the negative beliefs of others. Perhaps if the stigmatising beliefs of others were reduced, the perceived stigma and internalised stigma reduction will follow. Put (over)simply, if people stop thinking bad things about a group, that group might stop believing that people think bad things about them. Back to the lack of surprise couch.

Most stigma-intervention research has been undertaken among students in tertiary education settings and there appears to be very little quality research of anti-stigma interventions among members of the general community, health professionals, the workplace, in schools, or anywhere else really. Additionally, very little anti-stigma intervention research has been undertaken outside of the United States and Australia or in low and middle income countries, and only 20% of the studies have undertaken follow-ups of 6 months or more. Basically, we don’t know if anti-stigma interventions would work outside of these countries or if they work for any length of time.

Author conclusions

The authors concluded that current mental illness stigma interventions are effective in reducing personal stigma, but that more research is required to establish whether stigma interventions can be effective for perceived or internalised stigma and for specific mental illness diagnoses. They also observed that the effect sizes of the interventions were generally small and further research is clearly required to develop more effective interventions for reducing stigma.

The finding that anti-stigma interventions delivered using the internet were as effective as interventions delivered using other means raises the possibility that online delivery may be an effective approach. Face-to-face delivery in schools or in the workplace has substantial resource implications and the quality of training may vary. Interventions delivered online can be available more flexibly, using resources and with high fidelity in quality.

Summary

In general, the study found that anti-stigma interventions were associated with a small, but significant reduction in personal stigma.

• Educational interventions alone or when combined with other interventions were generally consistently associated with a reduction in personal stigma for different types of mental illness diagnosis
• Cognitive behaviour therapy was not effective in reducing personal stigma
• There were fewer studies of the effectiveness of interventions for reducing perceived and internalised stigma, but ultimately the meta-analyses did not find evidence of the effectiveness of interventions for reducing these two types of stigma.

These attempts to change negative attitudes against people with a mental illness diagnosis are a positive step. If education can change these attitudes then hopefully the awful consequences of such attitudes will also fade, especially if research can identify more effective ways of delivering this education. Perhaps it’s sad that we need to teach people not to treat a potentially already distressed group better, but as a great philosopher once said:

I’m just trying to find a quote that pithily shows why you should treat people with a mental illness badly. Something to do with them being people. I’m sure someone has said something.

Links

Griffiths KM, Carron-Arthur B, Parsons A and Reid R. Effectiveness of programs for reducing the stigma associated with mental disorders. A meta-analysis of randomized controlled trials. World Psychiatry 2014;13(2):161−75.

Stigma and Discrimination. Time to Change website, last accessed 17 Oct 2014.

Corrigan PW and Watson AC. Understanding the impact of stigma on people with mental illness. World Psychiatry 2002;1(1):16−20.

Dinos S, Stevens S, Serfaty M, Weich S and King M. Stigma: the feelings and experiences of 46 people with mental illness: Qualitative study (PDF). Br J Psychiatry 2004;184:176−81.