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

Treatment delays for mental disorders in Singapore: results from the Singapore Mental Health Study 2016

PURPOSE

Although the trajectory of mental disorders can be improved with timely treatment, many people defer treatment-seeking. This study aimed to examine the prevalence and correlates of treatment delays for mental disorders in Singapore, as well as perceived effectiveness of treatment received.

METHODS

A total of 6126 respondents, aged 18 and above, participated in the Singapore Mental Health Study 2016-a cross-sectional, nationwide study conducted in Singapore from 2016 to 2018. Lifetime treatment contact for mood, anxiety, and alcohol use disorders (AUD) was assessed using the World Mental Health-Composite International Diagnostic Interview (Version 3.0). Multivariable logistic regression was conducted to examine correlates of delayed treatment.

RESULTS

A total of 137 participants had made lifetime treatment contact for a mental disorder. The proportion of respondents who received delayed treatment (i.e., at least one year after onset of disorder) was 60.8% for any disorder, 59.5% for mood disorders, 56.3% for anxiety disorders, and 92.7% for AUD. The median delay was 5 years for mood disorders, one year for anxiety disorders, and 4 years for AUD. Treatment delay was significantly associated with older age, higher educational qualification, lifetime AUD, and earlier age of onset of disorder. 58.4% of respondents with lifetime treatment contact had received treatment that they considered effective.

CONCLUSION

The high prevalence and long durations of treatment delay underscore the need to encourage help-seeking for mental disorders, especially since treatment is generally perceived to be helpful. Our findings also highlight several population groups more susceptible to receiving delayed treatment.

Do Types of Information in an Animated Video Intervention Affect University Students' Autism Knowledge and Openness Towards Peers on the Autism Spectrum?

This pre-test post-test control group design sought to compare the effectiveness of delivering different types of information ([1] factual information vs. [2] factual information + descriptive and explanatory information vs. [3] factual information + descriptive, explanatory + directive information) in an animated video intervention in increasing university students' autism knowledge and openness toward peers on the autism spectrum. The sample consisted of 92 undergraduates (27 males, 65 females; age range = 18-36) from various universities in Singapore. Participants were randomly assigned to one of the three experimental conditions/videos, where they completed a measure of their autism knowledge and openness scale, before viewing a 5-minute long animated video containing different types of information about autism. After which, participants completed the measure of autism knowledge and openness scale again, followed by a measure of their empathy level. Results indicated that participants' autism knowledge improved following the viewing of the animated video. However, the three different videos containing different types of information did not differ in influencing participants' openness toward peers on the autism spectrum. Nevertheless, qualitative responses proposed that the video containing factual information, with descriptive, explanatory, and directive information was useful in helping participants to know how to interact with their peers on the autism spectrum. The findings of this study provide preliminary support for the most effective method to educate and raise awareness about autism, among the general student population in order to foster a supportive and inclusive environment.

Identification of Sociodemographic and Clinical Factors Influencing the Feeling of Stigmatization in People with Type 1 Diabetes

BACKGROUND

A large percentage of people with type 1 diabetes experience stigma, which may directly affect diabetes management. Moreover, it may adversely influence the acceptance of the disease and, thus, the treatment process, including compliance with medical and dietary recommendations. Therefore, it is important to seek adequate forms of counteracting the phenomenon of stigmatization. Thus, the aim of the study was to determine the factors influencing the level of perceived stigma by T1D patients, with particular emphasis on sociodemographic factors (including sex, place of residence, and education) and clinical factors related to the course of the disease.

METHODS

An observational cross-sectional online questionnaire was conducted in a group of 339 people with T1D. The link to the questionnaire was shared via social media. The DSAS-1 questionnaire translated into Polish was used as the research tool.

RESULTS

A moderate level of stigmatization was found (49.78 ± 14.54 points). It was significantly lower in people living in small towns compared to rural residents (ß = -0.121, p = 0.038), lower in people in relationships compared to those who are single (ß = -0.175, p = 0.001), in people diagnosed with T1D at an older age (ß = -0.107, p = 0.048), and in those who rated their financial situation as very good vs. bad (ß = -0.314, p < 0.001). It was also found that the level of stigma significantly decreased with age (ß = -0.181, p = 0.001). In addition, a significantly higher stigma perception was uncovered in the group of people with HbA1C > 7% than in the group ≤ 7% (ß = 0.118, p = 0.030).

CONCLUSIONS

Due to the occurrence of stigma among people with T1D, which can directly affect the management of diabetes, effective and comprehensive efforts should be made to provide support to people with diabetes. It is also necessary to raise awareness among the general public and disseminate knowledge about diabetes, which can reduce stigmatization as a result. Anti-stigma messages should be included in the prevention programs about the potential side effects and risks associated with mistreating people with T1D.

"Looking beyond Mental Health Stigma": An Online Focus Group Study among Senior Undergraduate Nursing Students

Evidence highlights the need for professionals to be aware of their stigmatizing attitudes and discriminatory practices in order to minimize the negative impact on the people they take care of. However, nursing students' perceptions of these issues have been poorly studied. This study explores the perspective of senior undergraduate nursing students on mental health and the stigma around it, by considering a simulated case vignette of a person with a mental health problem. A descriptive qualitative approach was chosen and involved three online focus group discussions. The findings show various manifestations of stigma, both at an individual and collective level, which indicates that it is an obstacle to the wellbeing of people with mental illness. Individual manifestations of stigma concern its effect on the person with mental illness, while at the collective level they concern the family or society in general. Stigma is a multifactorial, multidimensional, and complex concept, in terms of identifying and fighting it. Thus, the strategies identified involve multiple approaches at the individual level, aimed at the patient and family, namely through education/training, communication, and relationship strategies. At the collective level, to intervene with the general population and specific groups, such as groups of young people, strategies suggested include education/training, use of the media, and contact with people with mental disorders as ways to fight stigma.

Employer and Co-worker Perspectives on Hiring and Working with People with Mental Health Conditions

The purpose of this study was to understand perspectives towards hiring and working with people with mental health conditions (PMHC). Semi-structured interviews with 25 employers and 20 co-workers were carried out. Thematic analysis was used to analyse the data. The barriers to hiring and working with PMHC identified through the interviews were concerns about safety, incompetence, PMHC not being able to get along with others, requiring more training and supervision as well as medical costs and reputational risks to the hiring organisation. Employers and co-workers suggested that improving mental health literacy of staff, pairing the PMHC with trained work buddies, having access to mental professionals when needed, and providing incentives for hiring PMHC such as tax rebates are likely to improve attitudes towards hiring and working with PMHC. Their suggestions for the additional supports required should be considered when developing initiatives to promote inclusivity of PMHC in workplaces.

A prospective observational study exploring the association of comorbid chronic health conditions with total healthcare expenditure in people with mental health conditions in an Asian setting

BACKGROUND

It is pertinent to focus on chronic medical condition (CMC) comorbidity with mental health conditions (MHC) as their co-occurrence has significant cost and health implications. However, current evidence on co-occurrence of MHC with CMC is mixed and mostly from Western settings. Therefore, our study aimed to (i) describe the association between MHC and total healthcare expenditure, (ii) examine the association between CMC and total healthcare expenditure and (iii) examine determinants of total and different types of healthcare expenditure in respondents with and without MHC in an Asian setting.

METHODS

The data from Singapore Mental Health Study (SMHS) 2016, a nationwide epidemiological survey, were linked with the National claims record (from 2017 to 2019). Multivariable Generalized Linear Models (GLM) were used to examine the association between MHC and total and different types of healthcare expenditure.

RESULTS

A total of 3077 survey respondents were included in current analysis. Respondents with MHC had a lower mean age of 38.6 years as compared to those without MHC (47.1 years). MHC was associated with increased total healthcare expenditure after adjusting for covariates (b = 0.508, p < 0.05). In respondents with MHC, presence of CMC increased the total healthcare expenditure by 35% as compared to 40% increase in those without MHC. Interestingly, 35-49 years age group with MHC had almost 3 times higher total healthcare expenditure and 7.5 times higher inpatient expenditure as compared to the 18-34 years age group.

CONCLUSION

Our study highlights variations in association of CMC and age with total healthcare expenditure in those with versus without MHC in an Asian setting. Practical recommendations include appropriate planning and resource allocation for early diagnosis and management of MHC, proactive screening for CMC in those with MHC and addressing the dual issues of treatment gap and stigma to facilitate early help seeking and prevent episodic, costly healthcare utilization.

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.

Prevalence and Correlates of Social Stigma Toward Diabetes: Results From a Nationwide- Survey in Singapore

Aims: To examine the extent of social stigma toward diabetes among Singapore's multi-ethnic general population and determine whether this differs across socio-demographic sub-groups.

Methods: Data for this study came from a nationwide cross-sectional study. A diabetes stigma questionnaire comprising Social Distance Scale and Negative Attitudes and Stereotyping Scale was administered to those respondents who had not been diagnosed with diabetes. Exploratory factor analysis was conducted to determine the dimensionality of the instruments and validated using confirmatory factor analysis. Multiple linear regression analysis was conducted to examine associations between socio-demographic factors and measures of diabetes stigma.

Results: In all, 2,895 participants were recruited from the general population giving a response rate of 66.2%. Factor analyses found that a one-factor model resulted in an acceptable fit for both stigma scales, which measured social distance and negative attitudes and stereotyping, respectively. Multiple linear regression analyses identified Indian ethnicity (vs. Chinese), higher personal income (≥SGD2000 vs. < SGD 2000) and having close friends or family members who had been diagnosed with diabetes to be significantly associated with lower social distance scores while those aged 50–64 years and those with secondary and vocational education (vs. degree and above) were significantly associated with higher social distance scores. Those with a personal income of SG$2,000–3,999 and SGD $6,000 and above, and those with close friends or family members diagnosed with diabetes were significantly associated with lower negative attitudes and stereotyping scores. In contrast those aged 35 years and above, those with primary education and below, and those of Malay ethnicity were significantly associated with higher negative attitudes and stereotyping scores.

Conclusions: The study found a relatively low level of stigma toward diabetes in the general population of Singapore, although some stigmatizing beliefs emerged. While greater knowledge of diabetes could reduce stigma, anti-stigma messaging should be incorporated into the “War on Diabetes” programme in Singapore.

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 (β = - 1.19, 95% CI: - 2.10, - 0.27, p = 0.01) and nationality (β = - 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 (β = 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 (β = - 0.34, 95% CI: - 0.52, - 0.16, p <  0.001) and CMHI (β = - 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.

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.

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.