Stigmatization of psychiatric symptoms and psychiatric service use: a vignette-based representative population survey

Treatment-seeking threshold and accessibility of psychiatric outpatient services in Switzerland: the relationship with stigma and self-esteem

Perceived stigmatization and low self-esteem are linked to poorer mental health outcomes, but their impact on treatment-seeking thresholds and the importance of outpatient service location remain unclear. The study included 525 outpatients of the University Psychiatric Clinic (UPK) Basel, Switzerland, of whom 346 were treated at inner city services and 179 at services located on the main site of the UPK at the outer city limits. Perceived discrimination and devaluation (PDD), self-esteem (SE), treatment-seeking threshold (TST), and accessibility were measured via a self-reported questionnaire. The PDD consisted of 12 items evaluating beliefs about the level of stigma towards individuals with mental illness in the general population on a 5-point Likert scale. SE, TST and accessibility were assessed through single-item 7-point Likert scales. PDD and SE were positively correlated (p < 0.001), suggesting that lower perceived stigma was linked to higher self-esteem, and were not associated with TST. The relationship between PDD and SE remained consistent after controlling for age, gender, and nationality. Age was negatively correlated with TST (p = 0.022), while gender did not significantly influence any of the variables. There was little variation regarding PDD, with emergencies at the site of the psychiatric clinic and substance use disorder (SUD) patients reporting higher levels of stigmatization. Emergency patients and those with SUD and personality disorder reported the lowest SE ratings. TST showed a broad range and was highest for emergency services and transcultural psychiatry patients. Differences in accessibility were mainly linked to the location, with outpatient service users in the inner city reporting better accessibility (p < 0.001) and higher SE (p = 0.009). In comparison to patients using services with planned contacts only, patients in emergency settings differed by higher TST (p = 0.018) and better ratings of accessibility (p = 0.004). In conclusion, there was a relevant amount of stigmatization, impaired self-esteem, and, for some outpatient services, high thresholds to seek treatment. Future research should explore other factors influencing TST. The findings highlight the need to address stigmatization and accessibility when planning mental health services.

[The Attitude of the Public Concerning Coercive Measures in Psychiatric Patients]

OBJECTIVE

To examine the attitude of the general public in Basel concerning the use of coercive measures while dealing with psychiatric patients. The common population indirectly governs the use of coercive measures in psychiatry by its stigmatization of people with psychiatric illnesses, and its attitude towards treatment in psychiatry and by local opinion leaders and reactions of social networks.

METHODS

The answers of 1,112 persons from a representative population survey were evaluated. Participants were mailed case vignettes and questionnaires, and asked if they considered involuntary admission, coercive medication, and/or seclusion as acceptable measures in dealing with psychiatric patients.

RESULTS

When symptoms of a psychotic disorder were present, 31.5% approved of at least one coercive measure, with 22% approval in the case of a borderline personality disorder, and 20.7% in the case of alcohol dependency. However, the overall rejection of coercive measures by the general public in Basel was high. The differential approval of the examined coercive measures depending on psychiatric symptoms was in line with professional medical and ethical guidelines.

CONCLUSION

Public attitudes have an indirect influence on the local use of coercive measures and should be included in the specialist psychiatric discourse.

General and Case-Specific Approval of Coercion in Psychiatry in the Public Opinion

BACKGROUND

Psychiatric patients are subjected to considerable stigmatization, in particular, because they are considered aggressive, uncontrollable, and dangerous. This stigmatization might influence the approval of coercive measures in psychiatry by the public and healthcare professionals and might have an influence on the clinical practice of coercive measures. We examined whether the general approval of coercive measures for psychiatric patients with dangerous behaviors differs from case-specific approval.

METHOD

We conducted a representative survey of the general population (n = 2207) in the canton of Basel-Stadt, Switzerland. In total, 1107 participants assessed a case vignette depicting a fictitious character with a mental illness and indicated whether they would accept coercive measures (involuntary hospitalization, involuntary medication, and seclusion) for the person in the vignette. It was explicitly stated that within the last month, the fictitious character displayed no dangerous behavior (Vignette ND) or dangerous behavior (Vignette D). Another 1100 participants were asked whether they would approve coercive measures (involuntary hospitalization, involuntary medication, and seclusion) for psychiatric patients with dangerous behavior in general (General D), i.e., without having received or referring to a specific case vignette.

FINDINGS

The logistic regression model containing all variables explained 45% of the variance in approval of any type of coercive measures. Assessment of case vignettes without dangerous behavior (Vignette ND) was associated with significantly reduced approval of coercive measures compared to assessment of a case vignette with dangerousness (Vignette D), while approval for coercive measures in a person with mental health disorder with dangerous behavior in general (General D) was significantly higher than for the case vignette with dangerousness.

CONCLUSIONS

The general approval of coercive measures for people with mental disorders seems to differ depending on if the respondents are asked to give a general assessment or to examine a specific and detailed clinical case vignette, indicating an increased role of stigmatization when asking about generalized assessments. This may contribute to diverging findings on the acceptance of coercive measures in the literature and should be considered when designing future studies.

Compulsory psychiatric admissions in the canton of Basel-Stadt between September 2013 and April 2022: Analysis of the cantonal database of the Health Department of Basel-Stadt

BACKGROUND

According to federal and cantonal law, persons with an acute mental illness can be admitted to a psychiatric hospital or another suitable institution against their will, when other therapeutic options are not available or have been exhausted. In the canton of Basel-Stadt, this is the responsibility of public health officers employed by the division of Social Medicine of the cantonal Health Department.

AIMS

This study aims to elucidate which factors influence the decision-making of public health officers regarding compulsory admissions over the period from September 2013 to April 2022 in the canton of Basel-Stadt.

METHOD

Leveraging comprehensive clinical data from the health department of the canton Basel-Stadt (N = 5,'550), we estimated a mixed effects logistic regression model to identify factors contributing to the decision of public-health officers to compulsorily admit patients, while controlling for potential clustering effects among public health officers.

RESULTS

The risk for compulsory admissions was most strongly predicted by the presence of potential self-harm. In comparison, while being a strong predictor, potential harm to others played a considerably lesser role. Furthermore, psychiatric syndrome, previous compulsory admissions, and the specific context of evaluation were significant predictors. Finally, we found no meaningful personal bias among public health officers.

CONCLUSION

The results suggest that public health officers' decision-making regarding compulsory admissions focuses on preventing self-harm and, to a lesser degree, harm to others. This indicates that such measures are only used as a measure of last resort, which is in line with current evidence regarding the detrimental effects of compulsory measures on treatment outcomes in psychiatry. Our findings suggest that all relevant stakeholders, including the police, share this perspective. Decision-making regarding compulsory admissions was mostly free of personal biases, suggesting adherence to shared professional standards by public health officers.

Understanding stigma toward schizophrenia

Schizophrenia is arguably one of the most stigmatized psychiatric disorders, with patients frequently seeing the burden of stigmatization as a "second illness." Thus, the purpose of this study was to investigate the relationships among the main aspects of the stigma toward schizophrenia. This study used a vignette methodology with 2053 individuals from the general population in Italy. The main aspects of stigma - causal beliefs, recommended treatments, social distance, perception of dangerousness, and avoidance - were investigated through participants' responses, and a latent variable structural equation model (SEM) approach was used to test the relationships among them. Perceived dangerousness predicts the desire for social distancing from an individual with schizophrenia, which predicts the desire for avoidance. In addition, biogenetic causal beliefs of schizophrenia and position on the appropriate medical treatment predict the perception of dangerousness and thus a greater desire for social distance. This study contributes to the literature on the stigmatization of mental health by improving our understanding of the phenomenon. Highlighting the relationships between aspects of stigma allows for a discussion of the implications for anti-stigma interventions.

Experiences and challenges faced by community mental health workers when providing care to people with mental illness: a qualitative study

BACKGROUND

Mental illness is a major burden of disease worldwide. Community Mental Health Services (CMHS) are key to achieving community-based recovery for people with mental illness. In China, even though the community management of patients with mental illness is improving, the barriers faced by Community Mental Health Workers (CMHWs) are unclear. This study explores the difficulties and challenges in CMHS from the perspective of CMHWs. The results of this study may provide a practical basis for the training of CMHWs.

METHODS

We carried out a qualitative study using an empirical phenomenological approach. Nine CMHWs were recruited from nine communities in Wuhan, Hubei Province, using purposive and snowball sampling. Face to face semi-structured in-depth interviews were conducted with them from December 27 to 28, 2019. Interview recordings were converted to text content by Nvivo 11.0 software and analyzed using Colaizzi's phenomenological method.

RESULTS

Three main themes were identified in this study: 1) Lack of role orientation leads to role ambiguity, 2) Failure to establish a therapeutic trust relationship with patients, and 3) Lack of communication and collaboration with various departments and peers. Seven sub themes were also identified. In these themes, CMHWs emphasized the importance of role clarity, therapeutic trusting relationships, and effective communication and coordination mechanisms.

CONCLUSION

Although China has made great efforts on the road to improving the quality of CMHS, several salient issues regarding CMHWs must be addressed to optimize the quality of services provided by CMHWs. Community mental health institutions should help CMHWs overcome these difficulties, by maximizing its value and promoting the development of CMHS.

Morally excused but socially excluded: Denying agency through the defense of mental impairment

Defendants can deny they have agency, and thus responsibility, for a crime by using a defense of mental impairment. We argue that although this strategy may help defendants evade blame, it may carry longer-term social costs, as lay people’s perceptions of a person’s agency might determine some of the moral rights they grant them. Three randomized between-group experiments (N = 1601) used online vignettes to examine lay perceptions of a hypothetical defendant using a defense of mental impairment (versus a guilty plea). We find that using a defense of mental impairment significantly reduces responsibility, blame, and punitiveness relative to a guilty plea, and these judgments are mediated by perceptions of reduced moral agency. However, after serving their respective sentences, those using the defense are sometimes conferred fewer rights, as reduced agency corresponds to an increase in perceived dangerousness. Our findings were found to be robust across different types of mental impairment, offences/sentences, and using both manipulated and measured agency. The findings have implications for defendants claiming reduced agency through legal defenses, as well as for the broader study of moral rights and mind perception.

Personality, self-esteem, familiarity, and mental health stigmatization: a cross-sectional vignette-based study

There has been little research exploring the relationship between personality traits, self-esteem, and stigmatizing attitudes toward those with mental disorders. Furthermore, the mechanisms through which the beholder’s personality influence mental illness stigma have not been tested. The aim of this study is to examine the relationship between Big Five personality traits, self-esteem, familiarity, being a healthcare professional, and stigmatization. Moreover, this study aims to explore the mediating effect of perceived dangerousness on the relationship between personality traits and desire for social distance. We conducted a vignette-based representative population survey (N = 2207) in the canton of Basel-Stadt, Switzerland. Multiple regression analyses were employed to examine the associations between personality traits, self-esteem, familiarity, and being a healthcare professional with the desire for social distance and perceived dangerousness. The mediation analyses were performed using the PROCESS macro by Hayes. Analyses showed associations between personality traits and stigmatization towards mental illness. Those who scored higher on openness to experience (β = − 0.13, p < 0.001), (β = − 0.14, p < 0.001), and those who scored higher on agreeableness (β = − 0.15, p < 0.001), (β = − 0.12, p < 0.001) showed a lower desire for social distance and lower perceived dangerousness, respectively. Neuroticism (β = − 0.06, p = 0.012) was inversely associated with perceived dangerousness. Additionally, high self-esteem was associated with increased stigmatization. Personal contact or familiarity with people having mental disorders was associated with decreased stigmatization. Contrarily, healthcare professionals showed higher perceived dangerousness (β = 0.04, p = 0.040). Finally, perceived dangerousness partially mediated the association between openness to experience (indirect effect = −  .57, 95% CI [− .71, − 0.43]) as well as agreeableness (indirect effect = − 0.57, 95% CI [− 0.74, − 0.39]) and desire for social distance. Although the explained variance in all analyses is < 10%, the current findings highlight the role of personality traits and self-esteem in areas of stigma. Therefore, future stigma research and anti-stigma campaigns should take individual differences into consideration. Moreover, the current study suggests that perceived dangerousness mediates the relationship between personality traits and desire for social distance. Further studies are needed to explore the underlying mechanisms of such relationship. Finally, our results once more underline the necessity of increasing familiarity with mentally ill people and of improving the attitude of healthcare professionals towards persons with mental disorders.

Approval of Coercion in Psychiatry in Public Perception and the Role of Stigmatization

Background: Coercion is routinely used in psychiatry. Its benefits and drawbacks are controversially debated. In addition, the majority of persons with mental health problems are exposed to stigmatization and are assumed to be dangerous. Stigmatization is associated with negative consequences for individuals with mental illness such as disapproval, social rejection, exclusion, and discrimination. Being subjected to coercive measures can increase the stigmatization of the affected persons, and stigmatization might lead to higher approval for coercion. Aims of the Study: This study aims to examine the approval for coercive measures in psychiatry by the general public, and to explore its relation with person- and situation-specific factors as well as with stigmatization. Method: We conducted a representative survey of the general population (N = 2,207) in the canton of Basel-Stadt, Switzerland. Participants were asked to read a vignette depicting psychopathological symptoms of a fictitious character and indicate whether they would accept coercive measures for the person in the vignette. Desire for social distance and perceived dangerousness were assessed as measures of stigmatization. Findings: The person in the case vignette exhibiting dangerous behavior, showing symptoms of a psychotic disorder, being perceived as dangerous, and treatment being understood as helpful increased approval of coercion in general, while familiarity of the respondents with mental illness decreased approval. Conclusions: The public attitude regarding the approval of coercion in psychiatry is highly differentiated and largely follows the current legal framework and medical treatment guidelines. Higher approval occurred in situations of self-harm or harm to others and when coercive measures were thought to have a beneficial effect for the affected persons. A considerable part of the approval for coercion is predicted by stigmatization. With the increasing severity of coercive measures, the influence of person- and situation-specific factors and of familiarity with mental illness decreased and generalizing and stigmatizing attitudes became stronger predictors for the approval of more severe measures.

Public stigma towards informal caregiving in Germany: a descriptive study

OBJECTIVES

This study aims to investigate the public stigma towards informal caregivers of individuals aged 65 years and older in the German population.

METHOD

In an Online-Survey 1038 participants (18 years and older and living in Germany) were sampled using a quota-system based on the German micro census data. To assess public stigma towards informal caregiving for individuals aged 65 years and older, three aspects of stigma were assessed: 1) emotional reactions (adapted Emotional Reaction to Mental Illness Scale), 2) behavioral reactions (adapted Social Distance Scale), and 3) cognitive reactions (newly developed List of Cognitions regarding informal caregiving). Exploratory and confirmatory factor analyses were conducted for the development and adaptation of the three instruments, and their composite reliability is provided.

RESULTS

Emotional reactions in terms of devaluing feelings and feelings of misery were low, while appreciative feelings were neither low nor high. Reported social distance was low. Agreement with cognitions towards informal care in terms of devaluing and accusative cognitions was on average low, but high regarding appreciative cognitions.

CONCLUSION

The results show that there is stigma towards informal caregiving for older individuals (65 years and older) in terms of emotional reactions, cognitions and social distance, although the magnitude of this stigma seems to be small. Knowledge regarding the occurrence and magnitude of stigma, as well as the processes that underlie this, is needed to prevent stigmatization and its negative outcomes, or at the very least, to enable the development of support for the affected individuals.

Morally excused but socially excluded: Denying agency through the defense of mental impairment

Defendants can deny they have agency, and thus responsibility, for a crime by using a defense of mental impairment. We argue that although this strategy may help defendants evade blame, it may carry longer-term social costs, as lay people’s perceptions of a person’s agency might determine some of the moral rights they grant them. In this registered report protocol, we seek to expand upon preliminary findings from two pilot studies to examine how and why those using the defense of mental impairment are seen as less deserving of certain rights. The proposed study uses a hypothetical vignette design, varying the type of mental impairment, type of crime, and type of sentence. Our design for the registered study improves on various aspects of our pilot studies and aims to rigorously test the reliability and credibility of our model. The findings have implications for defendants claiming reduced agency through legal defenses, as well as for the broader study of moral rights and mind perception.

Stigmatization of people with alcohol use disorders: An updated systematic review of population studies

BACKGROUND

We summarize research on the public stigmatization of persons with alcohol use disorder (AUD) in comparison with other mental health conditions and embed the results into a conceptual framework of the stigma process.

METHODS

We conducted a systematic search using Embase, MEDLINE, PubMed and PsycINFO (via Ovid), and Web of Science for population-based studies on the public stigma in AUD and at least 1 other mental health condition, published between October 1, 2010 and December 20, 2020, thus including all studies published since the last systematic review on this topic. The study is registered with PROSPERO (registration number: CRD42020173054).

RESULTS

We identified 20,561 records, of which 24 met the inclusion criteria, reporting results from 16 unique studies conducted in 9 different countries. Compared to substance-unrelated mental disorders, persons with AUD were generally less likely to be considered mentally ill, while they were perceived as being more dangerous and responsible for their condition. Further, the public desire for social distance was consistently higher for people with AUD. We found no consistent differences in the public stigma toward persons with AUD in comparison with other substance use disorders.

CONCLUSION

The stigmatization of persons with AUD remains comparatively high and is distinct from that of other substance-unrelated disorders.

Opening the Doors of a Substance Use Disorder Ward-Benefits and Challenges From a Consumer Perspective

Open doors in psychiatry have been a subject of controversy in recent years. While some studies postulate the clinical necessity of closed doors, others challenge the theoretical advantages of this setting, mention numerous drawbacks of closed wards, and focus on the advantages of open-door settings. With regard to patients diagnosed with substance use disorders (SUD), other standards may apply. Very little research has been done on this topic. Some studies adopted a consumer perspective (i.e. asking involved parties about their experience of the door status). To the authors' knowledge, no study has so far addressed the ideal setting for the treatment of SUD. With our data from the opening of a specialized SUD ward, we take one step to closing this knowledge gap. Applying a qualitative design, we asked patients and health care professionals (HCP) to report changes following the opening of the ward. The results are mainly in line with the literature on the general psychiatric population. The newly introduced open-door setting was mostly perceived as positive, but some disadvantages were mentioned (e.g. less protection of patients, less control over who enters/leaves the ward, the theoretically increased risk of patients absconding). Moreover, HCP (but not patients) mentioned potentially increased substance use on the ward as an additional disadvantage that could arise. Opening a previously closed ward was generally perceived as a positive and progressive decision. These findings support the trend towards an overall open-door policy in psychiatry.

Could Animal-Assisted Therapy Help to Reduce Coercive Treatment in Psychiatry?

For psychiatric patients, compulsory admission and coercive measures can constitute distressing and sometimes traumatizing experiences. As a consequence, clinicians aim at minimizing such procedures. At the same time, they need to ensure high levels of safety for patients, staff and the public. In order to prevent compulsory measures and to favor the use of less restrictive alternatives, innovative interventions improving the management of dangerous situations are needed. Animal-assisted therapy (AAT) is being applied in a variety of diagnoses and treatment settings, and could have the potential to reduce aggression and psychopathology. Therefore, AAT might be of use in the prevention and early treatment of aggression, and might constitute a promising component of treatment alternatives to forced interventions. To our knowledge, no study evaluating the effect of AAT on compulsory measures in persons with psychiatric diseases has been published up to date. This narrative expert review including a systematic literature search examines the published literature about the use of AAT in psychiatry. Studies report reduced anxiety and aggressiveness as well as positive effects on general wellbeing, self-efficacy, quality of life and mindfulness. Although literature on the applicability of AAT as a component of preventive or de-escalating treatment settings is sparse, beneficial effects of AAT have been reported. Therefore, we encourage examining AAT as a promising new treatment approach to prevent compulsory measures.

[Six years of open-door policy at the University Psychiatric Hospital Basel]

BACKGROUND

Coercive measures in psychiatry have well-known negative consequences for the patients and their treatment. They are considered ethically problematic and must only be used as a last resort. Locked wards may promote a threatening atmosphere leading to more aggression and a subsequent higher use of coercive measures. The aim of this was to investigate the frequency of seclusion and forced medication during clinic-wide implementation of an open-door policy.

MATERIAL AND METHODS

In this 6‑year longitudinal observational study (2010-2015) the frequencies of seclusion and forced medication were investigated on the basis of 17,359 cases treated in the University Psychiatric Hospital Basel. During the observational period, six formerly permanently locked wards were opened.

RESULTS

The examined data showed a clinically relevant decrease in the frequency of seclusion (from 8.2% to 3.5%) and forced medication (from 2.4% to 1.2%) during the observational period.

CONCLUSION

These results underline the potential of a less restrictive policy in psychiatry to reduce the frequency of coercive measures.

Mandated Treatment and Its Impact on Therapeutic Process and Outcome Factors

Court-mandated treatments imply a dual role for therapy providers not only of caring for, but also of having control over, involuntary clients. The impact of legal coercion on the therapeutic relationship and feelings of stigma is widely regarded as negative and detrimental for treatment outcomes. This point of view stands in contrast to advocates of the perspective that involuntary treatment can ameliorate social functioning and thus promote a better quality of life. Regarding other outcome measures, there is evidence that offender treatment is effective and leads to reduced recidivism in criminal behavior. This narrative review provides an overview of research assessing the effects of mandatory treatment on therapeutic process and outcome factors. We conclude that legal mandatory treatment does not have to necessarily result in perceived coercion and reduced satisfaction with treatment and that a caring and authoritative treatment style aids a favorable therapeutic alliance, motivation, and therapy outcomes.

Compulsory Admission to Psychiatric Wards-Who Is Admitted, and Who Appeals Against Admission?

Background: When persons with a mental illness present a danger to themselves or others, involuntary hospital admission can be used to initiate an immediate inpatient treatment. Often, the patients have the right to appeal against compulsory admission. These processes are implemented in most mental health-care systems, but regulations and legal framework differ widely. In the Swiss canton of Basel-Stadt, a new regulation was implemented in January 2013. While the current literature holds some evidence for factors associated with involuntary admission, knowledge on who uses the right to appeal against admission is sparse. Aims: The study aims to examine if specific sociodemographic and clinical characteristics are associated with involuntary admission and with an appeal against the compulsory admission order. Method: Routine clinical data of all inpatient cases admitted during the period from January 2013 to December 2015 at the Psychiatric University Hospital Basel were extracted. Generalized estimating equation (GEE) analyses were used to examine the association of sociodemographic and clinical characteristics with "involuntary admission" and "appeal against compulsory admission order." Results: Of the 8,917 cases included in the present study, 942 (10.6%) were admitted involuntarily. Of these, 250 (26.5%) lodged an appeal against the compulsory admission order. Compared with cases admitted on a voluntary legal status, cases admitted involuntarily were older and were admitted more often during the nighttime or weekend. Moreover, involuntarily admitted cases had more often a principal diagnosis of a schizophrenia spectrum disorder. Patients from cases where an appeal was lodged were more often female, had more often Swiss nationality, and were more often diagnosed with schizophrenia spectrum disorder. Conclusion: Despite legal changes, the frequency of involuntary admissions in the observed catchment area seems to be relatively stable across the last 20 years. The percentage of appeals has decreased from 2000 to 2015, and only comparably few patients make use of the possibility to appeal. Better knowledge of the regulations, higher social functioning, and lower insight into illness might be associated with a higher probability of lodging an appeal. Future research should examine if specific patient groups are in need of additional assistance to exert their rights to appeal.

Perceived Dangerousness as Related to Psychiatric Symptoms and Psychiatric Service Use - a Vignette Based Representative Population Survey

Perceptions of dangerousness are an influential component of mental health stigma and can be driven by the display of psychiatric symptoms and the use of psychiatric service institutions. Yet, no previous study compared symptoms and service use associated perceptions of dangerousness. Therefore, we conducted a representative survey (N = 2,207) in the canton of Basel-Stadt, Switzerland. Participants were asked to answer the perceived dangerousness scale with respect to a vignette that either depicted psychiatric symptoms of a fictitious character or a psychiatric service institution the fictitious character had been admitted to. Between the vignettes, type of symptoms, type of psychiatric service, dangerousness, and gender were systematically varied. Perceived dangerousness was significantly lower as related to psychiatric service use than related to psychiatric symptoms. Overall, symptoms of alcohol dependency, behavior endangering others, and male gender of the fictitious character tend to increase perceived dangerousness. Furthermore, being hospitalized in a psychiatric unit at a general hospital or the rater being familiar with psychiatric services tends to decrease perceived dangerousness. Effective anti-stigma initiatives should integrate education about dangerousness as well as methods to increase familiarity with psychiatry. Additionally, an integration of modern psychiatry in somato-medical care institutions might decrease stigmatization.