Anticipated and experienced stigma and discrimination in the workplace among individuals with major depressive disorder in 35 countries: qualitative framework analysis of a mixed-method cross-sectional study.

OBJECTIVES: Workplace stigmatisation and discrimination are significant barriers to accessing employment opportunities, reintegration and promotion in the workforce for people with mental illnesses in comparison to other disabilities. This paper presents qualitative evidence of anticipated and experienced workplace stigma and discrimination among individuals with major depressive disorder (MDD) in 35 countries, and how these experiences differ across countries based on their Human Development Index (HDI) level. DESIGN: Mixed-method cross-sectional survey. PARTICIPANTS, SETTING AND MEASURES: The qualitative data were gathered as part of the combined European Union Anti-Stigma Programme European Network and global International Study of Discrimination and Stigma Outcomes for Depression studies examining stigma and discrimination among individuals with MDD across 35 countries. Anticipated and experienced stigma and discrimination were assessed using the Discrimination and Stigma Scale version 12 (DISC-12). This study used responses to the open-ended DISC-12 questions related to employment. Data were analysed using the framework analysis method. RESULTS: The framework analysis of qualitative data of 141 participants identified 6 key 'frames' exploring (1) participants reported experiences of workplace stigma and discrimination; (2) impact of experienced workplace stigma and discrimination; (3) anticipated workplace stigma and discrimination; (4) ways of coping; (5) positive work experiences and (6) contextualisation of workplace stigma and discrimination. In general, participants from very high HDI countries reported higher levels of anticipated and experienced discrimination than other HDI groups (eg, less understanding and support, being more avoided/shunned, stopping themselves from looking for work because of expectation and fear of discrimination). Furthermore, participants from medium/low HDI countries were more likely to report positive workplace experiences. CONCLUSIONS: This study makes a significant contribution towards workplace stigma and discrimination among individuals with MDD, still an under-researched mental health diagnosis. These findings illuminate important relationships that may exist between countries/contexts and stigma and discrimination, identifying that individuals from very high HDI countries were more likely to report anticipated and experienced workplace discrimination.

'Lifts your spirits, lifts your mind': A co-produced mixed-methods exploration of the benefits of green and blue spaces for mental wellbeing.

INTRODUCTION: Mental health problems are a considerable public health issue and spending time in nature has been promoted as a way to access a range of psychological benefits leading to the development of nature-based interventions for people with severe and enduring mental health problems. Less, however, is understood about the potential benefits and efficacy of day-to-day routine access to outdoor green and blue spaces for mental health service users. METHODS: Using a mixed-methods design between April and October 2021, we explored the benefits and barriers to spending time outdoors with a purposive sample of mental health service users (N = 11) using qualitative interviews and an online general population survey (N = 1791). Qualitative evidence highlighted the restorative benefits of nature and identified a number of barriers associated with fears around personal safety, social anxiety, fatigue and lack of motivation. COVID-19 had also restricted access to green and blue spaces. Having social contact and support encouraged people to spend time outdoors. In the quantitative survey, self-report and standardised measures (the Patient Health Questionnaire and the Warwick-Edinburgh Wellbeing Scale) were used to assess past and current mental wellbeing. FINDINGS: Statistically significant differences were found between wellbeing and the use of green and blue spaces. Those with mental health problems spent time outdoors because they: felt guilty; wanted to reduce their anxiety; or rely on someone for encouragement. Those without mental health problems endorsed more positively framed reasons including relaxation, improving physical health or getting exercise. Barriers for people with mental health problems involved safety concerns, feeling anxious and having a poor self-image. These findings give insight into motivations for an outdoor activity to help inform the design of public mental health interventions. CONCLUSION: Further work is required to improve access and safety to promote the benefits of green and blue spaces for everyone. PATIENT OR PUBLIC CONTRIBUTION: The research team included expert experienced researchers with a mental health service provider (Praxis Care) and they were involved in the development of the research idea, funding application, design, data collection, analysis, writing up and dissemination activities.

Associations between dimensions of mental health literacy and adolescent help-seeking intentions.

BACKGROUND: The majority of long-term mental health problems begin during adolescence. Low mental health literacy (MHL) may impede help-seeking for these problems. Although MHL is a multidimensional construct and adolescent help-seeking can be through formal and informal means, little is known about how dimensions of MHL influence these help-seeking intentions. This study examines associations between dimensions of MHL and formal and informal help-seeking intentions among adolescents. It also investigates whether informal help-seeking mediates the association between dimensions of MHL and formal help-seeking, and whether these associations are moderated by gender. METHODS: A cross-sectional survey including measures of MHL, and help-seeking intentions was distributed to participants in 10 schools (12-17 years) across Scotland (n = 734). Data were analysed using Confirmatory Factor Analyses (CFA) and Structural Equation Modelling (SEM). RESULTS: Confirmatory Factor Analyses identified two distinct dimensions of MHL: ability to identify a mental health problem, and knowledge of treatment efficacy. Only knowledge of treatment efficacy was associated with increased intention to seek formal and informal help. Ability to identify a mental health problem was negatively associated with both forms of help-seeking intentions. Informal help-seeking mediated the association between both forms of MHL and formal help-seeking. Gender did not moderate the associations between MHL and help-seeking. CONCLUSIONS: Care should be taken when providing MHL interventions to ensure that adaptive forms of MHL are promoted. Future research should investigate possible mechanisms by which discrete forms of MHL influence adolescent help-seeking as well as investigating other potential moderators of MHL and help-seeking, such as stigma.

A Social-Ecological Approach to Understanding Adolescent Sexting Behavior.

This study examined the extent to which active and passive sexting behaviors are associated with family-, school-, peer-, and romantic-level variables. Young people (N = 3,322; 49.1% female, 48.3% male, 2.6% other) aged 11 to 15 years old (M = 12.84, SD = 0.89) took part, and all attended mainstream secondary schools in Scotland. Participants completed self-report measures of school connectedness, parental love and support, perceived susceptibility to peer- and romantic-pressure (e.g., to display behaviors just to impress others), and their involvement in active and passive sexting. The importance of both school- and family-level factors was evident, though perceived romantic-pressure had the largest effect. However, neither school- nor family-level variables were moderated by either perceived romantic-pressure or perceived peer-pressure. Efforts to reduce sexting or increase its safety should primarily seek to tackle young people's ability to respond effectively to romantic-pressure. It may also be helpful to develop school connectedness and to help families provide support that is constructive and not intrusive.

A scoping review of international policy responses to mental health recovery during the COVID-19 pandemic.

The COVID-19 pandemic has affected people's physical and mental health. Quarantine and other lockdown measures have altered people's daily lives; levels of anxiety, depression, substance use, self-harm and suicide ideation have increased. This commentary assesses how international governments, agencies and organisations are responding to the challenge of the mental health impact of COVID-19 with the aim of informing the ongoing policy and service responses needed in the immediate and longer term. It identifies some of the key themes emerging from the literature, recognises at-risk populations and highlights opportunities for innovation within mental health services, focusing on the published academic literature, international health ministry websites and other relevant international organisations beyond the United Kingdom and Ireland. COVID-19 has challenged, and may have permanently changed, mental health services. It has highlighted and exacerbated pre-existing pressures and inequities. Many decision-makers consider this an opportunity to transform mental health care, and tackling the social determinants of mental health and engaging in prevention will be a necessary part of such transformation. Better data collection, modelling and sharing will enhance policy and service development. The crisis provides opportunities to build on positive innovations: the adaptability and flexibility of community-based care; drawing on lived experience in the design, development and monitoring of services; interagency collaboration; accelerating digital healthcare; and connecting physical and mental health.

Poverty and mental health: policy, practice and research implications.

This article examines the relationship between poverty and mental health problems. We draw on the experience of Glasgow, our home city, which contains some of Western Europe's areas of greatest concentrated poverty and poorest health outcomes. We highlight how mental health problems are related directly to poverty, which in turn underlies wider health inequalities. We then outline implications for psychiatry.

Depression and anxiety among people living with and beyond cancer: a growing clinical and research priority.

BACKGROUND: A cancer diagnosis can have a substantial impact on mental health and wellbeing. Depression and anxiety may hinder cancer treatment and recovery, as well as quality of life and survival. We argue that more research is needed to prevent and treat co-morbid depression and anxiety among people with cancer and that it requires greater clinical priority. For background and to support our argument, we synthesise existing systematic reviews relating to cancer and common mental disorders, focusing on depression and anxiety. We searched several electronic databases for relevant reviews on cancer, depression and anxiety from 2012 to 2019. Several areas are covered: factors that may contribute to the development of common mental disorders among people with cancer; the prevalence of depression and anxiety; and potential care and treatment options. We also make several recommendations for future research. Numerous individual, psychological, social and contextual factors potentially contribute to the development of depression and anxiety among people with cancer, as well as characteristics related to the cancer and treatment received. Compared to the general population, the prevalence of depression and anxiety is often found to be higher among people with cancer, but estimates vary due to several factors, such as the treatment setting, type of cancer and time since diagnosis. Overall, there are a lack of high-quality studies into the mental health of people with cancer following treatment and among long-term survivors, particularly for the less prevalent cancer types and younger people. Studies that focus on prevention are minimal and research covering low- and middle-income populations is limited. CONCLUSION: Research is urgently needed into the possible impacts of long-term and late effects of cancer treatment on mental health and how these may be prevented, as increasing numbers of people live with and beyond cancer.

Cross-national variations in reported discrimination among people treated for major depression worldwide: the ASPEN/INDIGO international study.

BACKGROUND: No study has so far explored differences in discrimination reported by people with major depressive disorder (MDD) across countries and cultures. AIMS: To (a) compare reported discrimination across different countries, and (b) explore the relative weight of individual and contextual factors in explaining levels of reported discrimination in people with MDD. METHOD: Cross-sectional multisite international survey (34 countries worldwide) of 1082 people with MDD. Experienced and anticipated discrimination were assessed by the Discrimination and Stigma Scale (DISC). Countries were classified according to their rating on the Human Development Index (HDI). Multilevel negative binomial and Poisson models were used. RESULTS: People living in 'very high HDI' countries reported higher discrimination than those in 'medium/low HDI' countries. Variation in reported discrimination across countries was only partially explained by individual-level variables. The contribution of country-level variables was significant for anticipated discrimination only. CONCLUSIONS: Contextual factors play an important role in anticipated discrimination. Country-specific interventions should be implemented to prevent discrimination towards people with MDD.

Nature and impact of European anti-stigma depression programmes.

Stigma associated with depression is a major public health issue in the EU, with over 20 million people experiencing depression and its associated personal distress each year. While most programmes against stigma related to mental health problems are of a general nature, the knowledge about programmes tackling stigma against people with depression is limited. This study therefore aims to assess the nature and impact of depression-specific programmes in EU countries. Using a web-based tool, 26 programmes were identified across the 18 EU countries taking part in the study. Most were universal and targeted the whole population, while many also targeted specific population groups or settings, such as young people or health professionals. The most common programme aim was improving literacy, although reducing stigmatizing attitudes and discriminatory behaviour and promoting help-seeking were also common. Most programmes originated from professional bodies, or as grassroots initiatives from service user groups/NGOs, rather than as part of national and local policy. The approaches used were primarily different forms of education/information, with some, but very limited, use of positive personal contact. Overall, the quality and extent of impact of the programmes was limited, with few leading to peer-reviewed publications. Specific programmes were identified with evidence of positive impact, and we drew on these examples to develop a framework to be used for future programmes against stigma and discrimination associated with depression. These findings are provided in full in the Anti-Stigma Partnership European Network Toolkit available at www.antistigma.eu.

Beliefs, stigma and discrimination associated with mental health problems in Uganda: implications for theory and practice.

BACKGROUND: There are major gaps in knowledge about beliefs, stigma and discrimination in Uganda, including the relationship between different cultural beliefs and stigmatising responses, how stigma and beliefs result in discrimination and the impact of social factors such as gender, poverty and ethnic conflict. AIM: This exploratory study aims to understand beliefs, stigma and discrimination associated with mental health in Uganda in more depth from the perspectives of different stakeholders. METHODS: Focus groups and interviews were undertaken with mental health activists, policymakers, practitioners, non-governmental and human rights organisations, journalists and academics. RESULTS: Stigma was reported by individuals, families, communities and institutions, including health services. The study also found stigmatising beliefs linked to traditional, religious and medical explanatory frameworks, high levels of 'associated stigma', common mental health problems rarely medicalised and discrimination linked to poverty, gender and conflict. CONCLUSIONS: The findings suggest the need to address stigma in their cultural and social context, alongside other human rights initiatives.

Community conversation: addressing mental health stigma with ethnic minority communities.

INTRODUCTION: Stigma associated with mental health problems is a significant public health issue. Patterns of stigma and discrimination vary between and within communities and are related to conceptualisations of, and beliefs about, mental health. Population approaches to addressing stigma rarely consider diverse cultural understandings of mental health. METHODS: 257 members of the major black and minority ethnic communities in Scotland participated in 26 mental health awareness workshops that were designed and delivered by community organisations. Questionnaires measuring knowledge, attitudes and behavioural intent were completed before and after the intervention. RESULTS: Community led approaches that acknowledge cultural constructs of mental health were received positively by community groups. The study found significant reported stigma in relation to public protection, marriage, shame and contribution, but also high levels of recovery optimism. The workshops resulted in significant positive change in relation to knowledge, attitudes and behavioural intent amongst participants, with most aspects of stigma showing significant improvement, with the exception of dangerousness. DISCUSSION: The paper argues community approaches to tackling stigma are more valuable than top-down public education and could form the basis of national initiatives. Refinements to the evaluation framework are considered.