Study shows that social contact intervention may reduce mental health stigma, suggests solutions journalism ideas

Photo by Alachua County via Flickr.

One of the biggest barriers to seeking mental health care is stigma. While I can point to some studies that show this all over the world, the scale of the problem is most evident simply by doing a keyword search in PubMed. Stigma is particularly discouraging for those living with substance use disorders, including alcohol use disorder.

What if training and research related to mental illness involved the people who live with mental health conditions? Could that reduce at least some of the stigma that even many clinicians have, consciously or not, about their patients and the disorders they treat? Could it improve mental health care overall? According to a new pilot study that tested this, it appears it can.

Journalists might find the study’s findings interesting because it’s a rich area for story ideas:

  • Do mental health facilities in your area explicitly do training to reduce stigma in clinicians?
  • How are people generally trained in local mental health treatment centers in your area?
  • Have patients who have been in treatment programs felt as though they were treated with respect and dignity?
  • Could patients’ perception of stigma from their clinicians be discouraging them from continuing care?
  • Are any local mental health facilities considering including people with mental illness in their training programs?  

Any one of those questions or a half dozen others could lead to possible stories to explore on a local or national level. Let’s look at how the researchers conducted this study and what they found.

Study methodology

The study was conducted from February 2016-August 2018 in Nepal, which is important to note because attitudes toward mental illness may be very different in Nepal compared with the U.S. or other countries. But that doesn’t mean the findings are meaningless to U.S. health care. Stigma is a global problem with mental health care, so an intervention that addresses it in one country is worth considering in another.

Researchers randomly assigned clinicians at 34 primary care facilities to receive one of two types of training: staff were either trained using the World Health Organization Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG) or trained using mhGAP-IG but had “people with lived experience of mental illness” co-facilitating the training and sharing their own recovery testimonials with photos.

The study began with 88 primary care providers (PCPs), mostly men (85%) and mostly upper-caste Hindus (76%). After dropouts, the study ended with 33 PCPs in the control group (mhGAP-IG) and 33 PCPs in the intervention group (RESHAPE) from 29 total facilities. The study started with 15 co-facilitators who had been diagnosed with depression, psychosis, or alcohol use disorder, and 11 of them participated in training throughout the three months of the training.

At the start of the study and at 16 months after training, the PCPs were assessed in their accuracy of diagnosing mental illness in role-plays and with a Social Distance Scale that measures stigma by asking questions about how comfortable and willing clinicians are participating in activities with people who have a mental illness. The participating PCPs also completed the mhGAP Attitudes Assessment (assessing the participant’s stigmatizing beliefs and stereotypes), the Implicit Association Test (which tests implicit bias), a mhGAP Knowledge Assessment, and a tool to assess clinical competency. At 14 to 22 months after training, PCPs were assessed on their accuracy of diagnosing actual patients.

Analyzing the results

At the 16-month mark, clinicians participating in the control group had average scores on the Social Distance Scale drop 2.8 points, indicating less stigma and more willingness to spend time with people with mental illness. But among those who participated in the RESHAPE group, cofacilitated with people with mental illness, scores dropped an average 10.6 points, suggesting significantly less stigma. Both groups also improved in all other measures except the implicit bias test.

At 16 months after training, the RESHAPE group showed 78% accuracy in diagnosing actor-patients in role plays compared with 67% accuracy in the control group. The difference was even more dramatic with patients already diagnosed by a psychiatrist: the RESHAPE group showed 73% accuracy, and the control group only had 35% accuracy. The inaccurate diagnoses were all false positives — the PCPs diagnosed the patient with a condition they did not have —and the control group had more false positives than the RESHAPE group. The condition most often incorrectly diagnosed was depression.

The bottom-line

“The preliminary findings suggest that RESHAPE may have the potential to reduce stigma among PCPs without introducing a substantial risk of harm to people with a living experience of mental illness collaborating in trainings,” the authors concluded. They also noted that “Exposure to structured recovery testimonials from people with living experience of mental illness may help to increase accuracy of diagnosis by PCPs.” Why does that matter? “Misdiagnosis, especially of psychotic disorders, increases exposure to medications with adverse effects, and misdiagnosis is costly and stigmatizing for patients and families,” the authors wrote. (Story idea for journalists: Are there local facilities that have poor rates of misdiagnosis that can be shown through records and patient stories?)

In an accompanying editorialKarina Davidson, Ph.D., of Northwell Health’s Feinstein Institutes for Medical Research in New York, described other ways clinician stigma hurts patients. She cited a poll finding that over half (53%) of clinicians think patients with mental illnesses don’t care as much about preventive care as the general population, and 88% of clinicians weren’t confident these patients would follow preventive recommendations. Yet 88% of patients with mental illness were interested in improving their health, and 82% said they would try to change their lifestyle if their doctor recommended it.

” Furthermore, patients with serious mental illness have higher rates of preventable chronic conditions and higher premature death rates than the general population, even after excluding suicide and other unnatural causes,” Davidson wrote. “Consequently, it is possible that reducing stigmatizing attitudes by primary care clinicians through educational training could ultimately improve other aspects of care received by this large subpopulation of patients.”

This study was a pilot study, so it’s only a start to exploring how incorporating people with mental illness into training might reduce stigma among clinicians. It also doesn’t address stigma in the public. However, it shows that stigma does exist among primary care providers and that it’s malleable — and that addressing it may improve mental health care. These findings suggest a lot of possibilities for solutions journalism looking at reducing stigma in mental health.

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