The perspectives of healthcare professionals in mental health settings on stigma and recovery - A qualitative inquiry.

BACKGROUND: Mental health stigma is one of the most prominent barriers to recovery, and it is widely known that stigma may manifest differentially in different cultures. Healthcare professionals working closely with persons with mental illnesses (PMI) may provide important insights towards stigma that are otherwise unattainable from caregivers and consumers. However, there is a dearth of literature on healthcare professionals' perspectives on this topic. Thus, this study uses a multilevel approach to explore how stigma affects recovery from the perspectives of healthcare professionals that work closely with PMI in Singapore. METHODS: Semi-structured interviews were conducted with a total of 17 healthcare professionals who were working in mental health settings in Singapore. Participants were recruited via direct email invitation or through snowball sampling. Data collected was analysed with the inductive thematic analysis method. All coding and inter-rater analyses were performed with NVivo. RESULTS: The current study themes identified stigma-related factors that influence PMI's recovery from the perspectives of healthcare professionals working closely with PMI. These factors were organised into three overarching themes in a multilevel structure. The three themes were classified as Micro Factors (e.g., internalised stigma), Meso Factors (e.g., discrimination of people associated with the stigmatised group), and Macro Factors (e.g., structural stigma and stigma within healthcare settings). CONCLUSIONS: The findings of this study gave us a greater understanding of how stigma influences recovery in Singapore, which could be used to guide the development and implementation of future policies and strategies to promote recovery. Importantly, our results suggest that improving mental health literacy, addressing cultural misgivings towards mental illness, implementing recovery-oriented practices, and making insurance more accessible for PMI could mitigate the deleterious impact that stigma has on recovery.

Strategies to Reduce Mental Illness Stigma: Perspectives of People with Lived Experience and Caregivers.

BACKGROUND: Reducing the stigma surrounding mental illness is a global public health priority. Traditionally, anti-stigma campaigns were led by mental health professionals/organisations and had an emphasis on increasing mental health literacy. More recently, it has been argued that people with lived experience have much to contribute in terms of extending and strengthening these efforts. The purpose of this paper was to elicit views and suggestions from people with lived experience (PWLE) as well as from informal caregivers of people with mental health conditions, on effective strategies to combat the stigma surrounding mental illness. METHODS: Six focus group discussions (FGDs) were carried out with PWLE recruited at outpatient services at the Institute of Mental Health, Singapore, and five FGDs were carried out with informal caregivers who responded to advertisements for the study between March and November 2018. In all, the sample comprised 42 PWLE and 31 caregivers. All the FGDs were transcribed verbatim and were analysed using thematic analysis. A pragmatic approach was adopted for the study, and the researchers did not assume any particular philosophical orientation. RESULTS: Four overarching themes depicting strategies to combat stigma were identified through thematic analysis. They were (1) raising mental health awareness, (2) social contact, (3) advocacy by influential figures or groups, and (4) the legislation of anti-discriminatory laws. CONCLUSIONS: These strategies were in line with approaches that have been used internationally to disrupt the process of stigma. Our study has further identified nuanced details on how these strategies can be carried out as well as possible areas of priority in the Singapore landscape.

Employment of young people with mental health conditions: making it work.

PURPOSE: The current study was undertaken to understand and describe the meaning of work as well as the barriers and facilitators perceived by young people with mental health conditions for gaining and maintaining employment. MATERIALS AND METHODS: Employing a purposive and maximum variation sampling, 30 young people were recruited and interviewed. The respondents were Singapore residents with a mean age of 26.8 years (SD = 4.5, range 20-34 years); the majority were males (56.7%), of Chinese ethnicity (63.3%), and employed (73.3%), at the time of the interview. Verbatim transcripts were analysed using inductive thematic analysis. RESULTS: Three global themes emerged from the analyses of the narratives, which included (i) the meaning of employment, (ii) barriers to employment comprising individual, interpersonal and systemic difficulties and challenges participants faced while seeking and sustaining employment and (iii) facilitators of employment that consisted of individual and interpersonal factors that had helped the young persons to gain and maintain employment. CONCLUSIONS: Stigma and discrimination emerged as one of the most frequently mentioned employment barriers. These barriers are not insurmountable and can be overcome both through legislation as well as through the training and support of young people with mental health conditions.IMPLICATIONS FOR REHABILITATIONEmployment offers several benefits to people with mental health conditions, including improvement in economic status, self-efficacy, and empowerment.Stigma is a significant barrier to employment for young people with mental health conditions; remaining optimistic about career prospects and getting support from peers is vital to employment success.Disclosure of the mental health condition at the place of work is beneficial to the person's own recovery and helpful to others; however, young people must be empowered to choose when and what they want to disclose and under what circumstances.Families help young people with mental health conditions in achieving their employment goals by offering emotional and instrumental support, as well as motivating them to accomplish more.

A Qualitative Exploration of the Views of Policymakers and Policy Advisors on the Impact of Mental Health Stigma on the Development and Implementation of Mental Health Policy in Singapore.

Few studies have examined the views of policy makers regarding the impact of mental health stigma on the development and implementation of mental health policies. This study aimed to address this knowledge gap by exploring policymakers' and policy advisors' perspectives regarding the impact of mental health stigma on the development and implementation of mental health programmes, strategies, and services in Singapore. In all 13 participants were recruited for the study comprising practicing policymakers, senior staff of organisations involved in implementing the various mental health programmes, and policy advisors. Data was collected through semi-structured interviews, which were transcribed verbatim and analysed using reflexive thematic analysis. Data analysis revealed three superordinate themes related to challenges experienced by the policymakers/advisors when dealing with mental health policy and implementation of programmes. These themes included stigma as a barrier to mental health treatment, community-level barriers to mental health recovery, and mental health being a neglected need. Policymakers/advisors demonstrated an in-depth and nuanced understanding of the barriers (consequent to stigma) to mental healthcare delivery and access. Policymakers/advisors were able to associate the themes related to the stigma towards mental illness with help-seeking barriers based on personal experiences, knowledge, and insight gained through the implementation of mental health programmes and initiatives.

Recognition of Depression and Help-Seeking Preference Among University Students in Singapore: An Evaluation of the Impact of Advancing Research to Eliminate Mental Illness Stigma an Education and Contact Intervention.

Background: The SMHS 2016 revealed that young adults in Singapore had the highest 12-month prevalence of mental disorders, with depression being the most prevalent condition. Additionally, the study found that those with higher education were less likely to seek treatment. The recognition of mental illness and knowledge of where to seek help has been found to influence one's ability to seek timely psychological help. This study thus aims to evaluate the effects of ARTEMIS, an education and contact intervention on university students' recognition of depression and help-seeking preference. Methods: A total of 390 university students were recruited over a period of 6-months (October 2018 to April 2019). Students had to attend a one-off intervention which comprised a lecture on depression and personal contact with a person with lived experience of mental illness. Recognition of depression and help-seeking preference were assessed using a vignette approach, at pre- and post-intervention as well as at 3-month follow-up. Results: The intervention was effective at improving student's recognition of depression and this effect was sustained at 3-months follow-up. The intervention was also effective in shifting student's help-seeking preference, although the effects were not sustained at 3-month follow-up. Having a close friend or family with mental illness was associated with better recognition, and being able to correctly recognize depression was linked to a preference to seek psychiatric over non-psychiatric help. Conclusion: This study elucidated the efficacy of a knowledge-contact-based intervention in improving university students' recognition of depression and help-seeking preference. However, while the benefits on recognition of depression is more enduring, it is more transient for help-seeking beliefs, and booster sessions may be needed to improve the long-term effectiveness of the intervention on help-seeking preference. Lastly, to investigate the generalizability of this study's findings, future studies could replicate the current one across other non-self-selected samples, such as by integrating the intervention as part of student's orientation.

Advancing research to eliminate mental illness stigma: an interventional study to improve community attitudes towards depression among University students in Singapore.

BACKGROUND: After decades of anti-stigma initiatives, the Advancing Research To Eliminate Mental Illness Stigma (ARTEMIS) intervention study is one of the first in Singapore to evaluate the effects of an anti-stigma intervention on attitudes towards depression in university students. METHODS: 390 university students from a local university in Singapore were voluntarily recruited for the study. The ARTEMIS intervention comprises an educational and social contact component, as well as a question and answer (Q&A) session with experts in the area of mental health. The Community Attitudes towards Mental Illness (CAMI) scale was administered at baseline, post-intervention and at 3-months follow-up. A confirmatory factor analysis (CFA) was conducted. RESULTS: The CFA identified a 3-factor model for the CAMI with a decent fit (RMSEA = 0.06, CFI = 0.93, TLI = 0.93, SRMR = 0.06). Favourable shifts in attitudes across the factors were observed immediately after the intervention (p <  0.001). Gender (ß = - 1.19, 95% CI: - 2.10, - 0.27, p = 0.01) and nationality (ß = - 1.23, 95% CI: - 2.35, - 0.11, p = 0.03) were identified as significant correlates for the community mental health ideology (CMHI) factor. Linear effects indicated that having a close social contact with mental illness observed a smaller decrease in authoritarianism scores from pre- to post-intervention (ß = 0.85, 95% CI: 0.18, 1.53, p = 0.01); whereas quadratic effects found a greater decrease in scores from post-intervention to after 3-months for benevolence (ß = - 0.34, 95% CI: - 0.52, - 0.16, p <  0.001) and CMHI (ß = - 0.22, 95% CI: - 0.45, - 0.002, p = 0.048). CONCLUSION: The anti-stigma intervention shows promising short-term results across the CAMI dimensions even after adjusting for sociodemographic correlates. However, the intervention did not observe the sustained attitude shifts after 3-months. Recommendations for future anti-stigma interventions were also considered.

Caregivers' hopes, expectations and concerns surrounding the employment and future of young people with mental health conditions.

OBJECTIVE: Informal caregivers are often placed in a better position to understand and advocate for the vocational needs of young persons with mental health conditions. However, their opinions are largely ignored in the planning of vocational outcomes. This qualitative study had two broad aims: to explore (1) the perceptions of caregivers of young adults with mental health conditions on issues of paid employment and (2) their views and expectations of employment support services. METHODS: A total of 30 semi-structured interviews were conducted. Caregivers were 45 years old on average, the majority were women (73%) and were of Chinese ethnicity (53%). Most participants (60%) were parents of the young persons with psychotic disorders (57%), or affective and mood disorders, such as depression or anxiety disorders (43%). RESULTS: Thematic analyses of data revealed three superordinate themes: (1) caregiving roles, (2) caregivers' expectations and hopes, and (3) barriers to employmentof young persons with mental health conditions. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Caregivers strongly believed that employment support services should prioritise and advocate for recovery while securing employment. Local mental health employment support services should incorporate the views and expectations of caregivers of young persons with mental health conditions to foster better coordination between stakeholders, and enhance support for successful employment, reintegration into the community, and ultimately recovery for these individuals.

Daily Encounters of Mental Illness Stigma and Individual Strategies to Reduce Stigma - Perspectives of People With Mental Illness.

INTRODUCTION: A qualitative evaluation of mental illness stigma experienced by people with mental illness (PMI) is currently lacking in Singapore. This study aims to employ qualitative methods to identify the common encounters of mental illness stigma experienced by PMI in Singapore and uncover their individual strategies and efforts to reduce mental illness stigma. METHODS: This study is part of a larger research project that explores the concept of mental illness stigma among different stakeholders in Singapore. Focus group discussions (FGDs) were conducted with 42 PMI to collect qualitative data on their experience with mental illness stigma, including encounters of stigma and individual strategies to reduce stigma. The inductive thematic analysis method was employed to analyze the data. RESULTS: The eight emergent themes associated with encountering stigma in PMI's everyday life were categorized into two over-arching themes, public stigma (i.e., negative beliefs and attitudes, subjected to contemptuous treatment, social exclusion, over-scrutinizing, and receiving excessive care and concern) and structural stigma (i.e., the requirement to declare psychiatric conditions during job interviews, excluded from consideration after the declaration, and requirement of medical endorsements for employment). Four themes regarding PMI's individual strategies to reduce stigma were also identified (i.e., non-disclosure of condition, standing up for themselves, individual efforts in raising awareness, improving themselves, and living life as per normal). LIMITATIONS: Participants may be influenced by social desirability bias due to the presence of other participants in an FGD setting. Also, those who agreed to participate in the study may possess strong views or beliefs about mental illness stigma and may therefore be inherently different from those who refused to participate. CONCLUSION: Our findings on instances of public and structural stigma encountered by PMI in Singapore can guide policymakers with the development of future policies and strategies to reduce mental illness stigma in the Singapore society. Furthermore, our study also identified individual strategies that PMI employed to reduce mental illness stigma. However, the effectiveness of these strategies was unclear and little is known of their effect on PMI themselves. Hence, there is a need for future studies to examine these strategies.

The potential impact of an anti-stigma intervention on mental health help-seeking attitudes among university students.

BACKGROUND: The reluctance of young adults to seek mental health treatment has been attributed to poor mental health literacy, stigma, preference for self-reliance and concerns about confidentiality. The purpose of this study was to examine the potential impact of an anti-stigma intervention that includes education about depression, information about help-seeking as well as contact with a person with lived experience, on help seeking attitudes. METHODS: A pre-post study design was employed. Changes in help-seeking attitudes were measured using the Inventory of Attitudes towards Seeking Mental Health Services (IASMHS) immediately post-intervention and after 3 months. Sociodemographic data, information on past experiences in the mental health field and contact with people with mental illness were collated. Three hundred ninety university students enrolled in the study. Linear mixed models were used to examine the effects of the intervention. RESULTS: Scores on all subscales of the IASMHS, Psychological Openness (PO), Help-seeking Propensity (HP) and Indifference to Stigma improved significantly post-intervention and at 3-month follow-up compared to pre-intervention, with HP demonstrating the highest effect size. However, a significant decline was observed on all three scales at 3-month follow-up compared to post-intervention. Gender, having friends/family with mental illness, and previous experience in the mental health field moderated the intervention effects for the PO and HP subscales. CONCLUSION: The study showed that the brief anti-stigma intervention was associated with improvements in help-seeking attitudes among university students with differential effects among certain sub-groups. As the beneficial outcomes appeared to decrease over time, booster sessions or opportunities to participate in mental health-related activities post-intervention may be required to maintain the desired changes in help-seeking attitudes.

Mental illness stigma's reasons and determinants (MISReaD) among Singapore's lay public - a qualitative inquiry.

BACKGROUND: Mental illnesses pose a significant burden worldwide. Furthermore, the treatment gap for mental disorders is large. A contributor to this treatment gap is the perceived stigma towards mental illness. Besides impeding one's help-seeking intentions, stigma also impairs persons with mental illness (PMI) in other aspects of their life. Studies have found that stigma may manifest differentially under different cultural contexts. Thus, this study seeks to elucidate the determinants of stigma towards PMI among lay public in Singapore using a qualitative approach. METHODS: A total of 9 focus group discussions (FGD) were conducted with 63 participants consisting of lay public Singaporeans who were neither students or professionals in the mental health field, nor had they ever been diagnosed with a mental illness. Topics discussed during the FGD were related to the stigma of mental illness. Data collected were analyzed with inductive thematic analysis method. A codebook was derived through an iterative process, and data was coded by 4 different coders. Both coding and inter-rater analysis were performed with NVivo V.11. RESULTS: In total, 11 themes for the determinants of stigma were identified and conceptualized into a socioecological model. The socioecological model comprised 4 levels of themes: 1) Individual level beliefs (fear towards PMI, perceiving PMI to be burdensome, dismissing mental illness as not a real condition), 2) Interpersonal influences (upbringing that instills stigma, intergroup bias, perceived inability to handle interactions with PMI), 3) Local cultural values (elitist mindset among Singaporeans, Chinese culture of "face", Islamic beliefs about spiritual possession and reaction towards PMI), and 4) Shared societal culture (negative portrayal by media, Asian values). CONCLUSIONS: The findings of this study improved our understanding of the various reasons why stigma exists in Singapore. The themes identified in this study concur with that of studies conducted overseas, as some determinants of stigma such as fear towards PMI are quite ubiquitous. Specifically, the themes elitist mindset among Singaporeans and perceived inability to handle interactions with PMI were unique to this study. It is highly recommended that future anti-stigma campaigns in Singapore should incorporate the findings of this study to ensure cultural misgivings and beliefs are addressed adequately.

Advancing Research to Eliminate Mental Illness Stigma: The Design and Evaluation of a Single-Arm Intervention Among University Students in Singapore.

BACKGROUND: Anti-stigma interventions for school and college students have been studied in several countries, but to the best of our knowledge, this has not been addressed in Singapore. The current study was designed to address this lacuna and aimed to evaluate the effectiveness of an anti-stigma intervention focusing on depression among university students in Singapore. METHODS: A one-off intervention comprising education and personal contact with a person with lived experience of depression was carried out in nine consecutive sessions over 6 months (October 2018 to April 2019) among 390 university students. Knowledge of depression and extent of stigma toward mental illness were assessed pre- and post-intervention as well as at 3-month follow-up. RESULTS: The intervention was effective in improving depression knowledge (d = 1.09; p < 0.001), as well as reducing social distancing (d = 0.54; p < 0.001) and personal stigma (dangerous/undesirable: d = 0.60; p < 0.001 and weak not sick: d = 0.10; p < 0.033) pre- to post-intervention as well as pre- intervention to 3-month follow-up (p < 0.005). LIMITATIONS: While 3-month follow-up data indicates favorable medium-term impact on knowledge and stigma; the study lacks long-term follow-up to examine the impact of anti-stigma interventions across time. The data were collected through self-report measures; however, social desirability bias is possible despite the assurances of confidentiality. CONCLUSION: Given the impact of the intervention, there is a need to consider the feasibility, challenges, and enablers of implementation of such interventions into the curriculum of university students to ensure a broader and sustained outreach and stigma reduction.

Exploring Singapore's consumption of local fish, vegetables and fruits, meat and problematic alcohol use as risk factors of depression and subsyndromal depression in older adults.

BACKGROUND: Depression is a chronic mental disorder that severely impacts the older adult population globally. Nutritional psychiatry is an approach that has gained traction over the years. Exploring locally relevant consumption of common types of fish, vegetables and fruits (V&F), meat and problematic alcohol use (PAU) as risk factors associated with depression and subsyndromal depression (SSD) could reveal modifiable factors that could be targeted in the local older adult population in Singapore. METHODS: Data collected from the Well-being of the Singapore Elderly (WiSE) study, a cross-sectional population-based epidemiological study of Singapore's older adult population was analysed for the purposes of this study. Two thousand five hundred sixty-five participants were recruited and comprised of Singapore citizens and permanent residents aged ≥60 years. Data on fish, meat, and V&F consumption were collected using the sociodemographic and risk factor questionnaire. The CAGE (Cut, Annoyed, Guilt, and Eye-opener) questionnaire was used to determine PAU. The Geriatric Mental State-Automated Geriatric Examination for Computer Assisted Taxonomy (GMS-AGECAT) was used to obtain participants' diagnosis of depression or SSD. A multinomial logistic regression was used to explore the relationship between depression and dietary factors. RESULTS: Consumption of V&F in the last 3 days was less likely to be associated with depression and SSD. Frequent consumption of specific species of fish was associated with depression and SSD. PAU and the frequent consumption of Himantura gerrardi (stingray) were more likely to be associated with SSD. Finally, meat consumption was more likely to be associated with depression and SSD. CONCLUSIONS: The preliminary findings of the study support a need for healthy eating for the older adult population in Singapore. Further directions include a more thorough health and nutrition survey to capture accurate diets among the older adults in Singapore.