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Stigma and discrimination in relation to mental illnesses have been described as having worse consequences than the conditions themselves. Most medical literature in this area of research has been descriptive and has focused on attitudes towards people with mental illness rather than on interventions to reduce stigma. In this narrative Review, we summarise what is known globally from published systematic reviews and primary data on effective interventions intended to reduce mental-illness-related stigma or discrimination. The main findings emerging from this narrative overview are that: (1) at the population level there is a fairly consistent pattern of short-term benefits for positive attitude change, and some lesser evidence for knowledge improvement; (2) for people with mental illness, some group-level anti-stigma inventions show promise and merit further assessment; (3) for specific target groups, such as students, social-contact-based interventions usually achieve short-term (but less clearly long-term) attitudinal improvements, and less often produce knowledge gains; (4) this is a heterogeneous field of study with few strong study designs with large sample sizes; (5) research from low-income and middle-income countries is conspicuous by its relative absence; (6) caution needs to be exercised in not overgeneralising lessons from one target group to another; (7) there is a clear need for studies with longer-term follow-up to assess whether initial gains are sustained or attenuated, and whether booster doses of the intervention are needed to maintain progress; (8) few studies in any part of the world have focused on either the service user's perspective of stigma and discrimination or on the behaviour domain of behavioural change, either by people with or without mental illness in the complex processes of stigmatisation. We found that social contact is the most effective type of intervention to improve stigma-related knowledge and attitudes in the short term. However, the evidence for longer-term benefit of such social contact to reduce stigma is weak. In view of the magnitude of challenges that result from mental health stigma and discrimination, a concerted effort is needed to fund methodologically strong research that will provide robust evidence to support decisions on investment in interventions to reduce stigma. [ABSTRACT FROM AUTHOR]

Stigma and discrimination against people with mental ill health are global problems and have severe consequences in terms of social exclusion.[1] Such social exclusion is associated with barriers to health care,[[2]] increased unemployment,[4] and premature mortality.[5] Evidence is clear from high-income countries, and is emerging from low-income and middle-income countries (LMICs), that interventions can be effective in reducing such stigma and discrimination.[[6]] We now need a reappraisal of this field and a set of radical and practical recommendations to guide action locally, nationally, and globally to address mental health-related stigma and discrimination. Fourth, we will conduct a literature review on the effectiveness and cost-effectiveness of interventions to reduce stigma and discrimination related to mental illness. [Extracted from the article]

Background The CRIMSON (CRisis plan IMpact: Subjective and Objective coercion and eNgagement) study is an individual level, randomised controlled trial that compared the effectiveness of Joint Crisis Plans (JCPs) with treatment as usual for people with severe mental illness. The ICP is a negotiated statement by a patient of treatment preferences for any future psychiatric emergency, when he or she might be unable to express clear views. We assessed whether the additional use of JCPs improved patient outcomes compared with treatment as usual. Methods Patients were eligible if they had at least one psychiatric admission in the previous 2 years and were on the Enhanced Care Programme Approach register. The study was done with 64 generic and specialist community mental health teams in four English mental health care provider organisations (trusts). Hypotheses tested were that, compared with the control group, the intervention group would experience: fewer compulsory admissions (primary outcome); fewer psychiatric admissions; shorter psychiatric stays; lower perceived coercion; improved therapeutic relationships; and improved engagement. We stratified participants by centre. The research team but not participants nor clinical staff were masked to allocation. This study is registered with ClinicalTrials.gov, number ISRCTN11501328. Findings 569 participants were randomly assigned (285 to the intervention group and 284 to the control group). No significant treatment effect was seen for the primary outcome (56 [20%] sectioned in the control group and 49 [18%] in the JCP group; odds ratio 0.90 [95% CI 0.58-1.39, p=0.63]) or any secondary outcomes, with the exception of an improved secondary outcome of therapeutic relationships (17.3 [7.6] vs 16.0 [7.1]; adjusted difference -1.28 [95% CI -2.56 to -0.01, p=0.049]). Qualitative data supported this finding. Interpretation Our findings are inconsistent with two earlier JCP studies, and show that the JCP is not significantly more effective than treatment as usual. There is evidence to suggest the JCPs were not fully implemented in all study sites, and were combined with routine clinical review meetings which did not actively incorporate patients' preferences. The study therefore raises important questions about implementing new interventions in routine clinical practice. Funding Medical Research Council UK and the National Institute for Health Research. [ABSTRACT FROM AUTHOR]

The article presents a research study which examined the nature, direction, and severity of anticipated and experienced discrimination against people with schizophrenia. A cross-sectional survey was performed using face-to-face interviews of 732 participants with schizophrenia from 27 countries. The discrimination and stigma scale (DISC) was used to measure discrimination. The study found that negative discrimination was experienced by participants in a number of areas including in keeping a job and intimate relationships. Researchers concluded that anticipated and experienced discrimination rates were high across countries among people with mental illness. The authors note the need for interventions to improve self-esteem for people with mental illness.

The article examines the availability of mental health resources around the world, especially in low-income and middle-income countries. The article explains that mental health resources include policy and infrastructure within countries, mental health services, community resources, human resources, and funding. According to the article government spending on mental health in most developed countries is far lower than is actually needed, and the poorest countries in the world spend the lowest percentages of their overall health budgets on mental health. It is reported that the scarcity of available resources, along with inequities in their distribution and inefficiencies in their use pose the three main obstacles to better mental health.

The article discusses raising issue of how people with depression and anxiety in Great Britain receive treatment and mention Improving Access to Psychological Therapies (IAPT) programme. Topics discussed include bipolar illness among several patients along with personality disorder, people in World Bank high-income countries receiving treatment, and demand and supply in relation to mental health.

The article focuses on the Time to Change programme introduced in England on January 21, 2009 to reduce stigma and discrimination against people with mental health disorders. The initiative is being run by charities such as Mental Health Media, MIND and Rethink and is funded with £18 million from the Big Lottery Fund and Comic Relief. The programme is said to encourage individuals, communities and stakeholder organisations to take part in events, such as the Mental Health Awareness Week, using coordinated action at national and local levels. It also aims to augment the knowledge of discrimination by employers related to mental health as well as help people take legal action against organisations that have discriminated.

The article presents author's views on improving accessibility to psychological therapies and effective care in England. Topics discussed include Improving Access to Psychological Therapies (IAPT) programme and mental health services; association with practitioner-level factors; and mental conditions

A response from the authors of the article "Effectiveness of a Community-Based Intervention for People With Schizophrenia and Their Caregivers in India (COPSI): A Randomised Controoled Trial," in the September 13, 2014 issue is presented.

A response from the authors of the article "Effectiveness of a Community-Based Intervention For People With Schizophrenia and Their Caregivers in India (COPSI): A Randomised Controlled Trial" in a 2014 issue is presented.

Graham Thorncroft, Elaine Brohan, Diana Rose, Norman Satorius and Morven Leese respond to a letter to the editor about their article "Global Pattern of Experienced and Anticipated Discrimination Against People With Schizophrenia: A Cross-Sectional Survey" in the January 31, 2009 issue.

The article comments on the research being conducted by Phillip Wang and his colleagues, which examines how a large majority of people with mental illness worldwide are not being treated and are being neglected. The article explains that the research is the largest international psychiatric epidemiological study ever conducted. The study involved 85,000 members of the general popular were personally interviewed in 17 countries. It is suggested that a potential weakness of the study is how it defines minimally acceptable treatment. An overview of how the study was conducted is presented.

Psychiatric services in Ukraine, like in many other former Soviet republics, are characterised by institutionalisation and a focus on biological treatment. Under this social care home economy, each client with such a disability status has a pension, of which 75% is paid to the institution. 10 UN Human Rights Office of the High Commissioner Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. [Extracted from the article]

A letter to the editor is presented in response to the article "WHO's Director-General candidates: visions and priorities" by R. Horton and U. Samarasekera in the October 29, 2016 issue.

The burden of mental, neurological, and substance use (MNS) disorders increased by 41% between 1990 and 2010 and now accounts for one in every 10 lost years of health globally. This sobering statistic does not take into account the substantial excess mortality associated with these disorders or the social and economic consequences of MNS disorders on affected persons, their caregivers, and society. A wide variety of effective interventions, including drugs, psychological treatments, and social interventions, can prevent and treat MNS disorders. At the population-level platform of service delivery, best practices include legislative measures to restrict access to means of self-harm or suicide and to reduce the availability of and demand for alcohol. At the community-level platform, best practices include life-skills training in schools to build social and emotional competencies. At the health-care-level platform, we identify three delivery channels. Two of these delivery channels are especially relevant from a public health perspective: self-management (eg, web-based psychological therapy for depression and anxiety disorders) and primary care and community outreach (eg, non-specialist health worker delivering psychological and pharmacological management of selected disorders). The third delivery channel, hospital care, which includes specialist services for MNS disorders and first-level hospitals providing other types of services (such as general medicine, HIV, or paediatric care), play an important part for a smaller proportion of cases with severe, refractory, or emergency presentations and for the integration of mental health care in other health-care channels, respectively. The costs of providing a significantly scaled up package of specified cost-effective interventions for prioritised MNS disorders in low-income and lower-middle-income countries is estimated at US$3-4 per head of population per year. Since a substantial proportion of MNS disorders run a chronic and disabling course and adversely affect household welfare, intervention costs should largely be met by government through increased resource allocation and financial protection measures (rather than leaving households to pay out-of-pocket). Moreover, a policy of moving towards universal public finance can also be expected to lead to a far more equitable allocation of public health resources across income groups. Despite this evidence, less than 1% of development assistance for health and government spending on health in low-income and middle-income countries is allocated to the care of people with these disorders. Achieving the health gains associated with prioritised interventions will require not just financial resources, but committed and sustained efforts to address a range of other barriers (such as paucity of human resources, weak governance, and stigma). Ultimately, the goal is to massively increase opportunities for people with MNS disorders to access services without the prospect of discrimination or impoverishment and with the hope of attaining optimal health and social outcomes. [ABSTRACT FROM AUTHOR]

Background Observational evidence suggests that community-based services for people with schizophrenia can be successfully provided by community health workers, when supervised by specialists, in low-income and middle-income countries. We did the Community care for People with Schizophrenia in India (COPSI) trial to compare the effectiveness of a collaborative community-based care intervention with standard facility-based care. Methods We did a multicentre, parallel-group, randomised controlled trial at three sites in India between Jan 1, 2009 and Dec 31, 2010. Patients aged 16-60 years with a primary diagnosis of schizophrenia according to the tenth edition of the International Classification of Diseases, Diagnostic Criteria for Research (ICD-10-DCR) were randomly assigned (2:1), via a computer-generated randomisation list with block sizes of three, six, or nine, to receive either collaborative community-based care plus facility-based care or facility-based care alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. The primary outcome was a change in symptoms and disabilities over 12 months, as measured by the positive and negative syndrome scale (PANSS) and the Indian disability evaluation and assessment scale (IDEAS). Analysis was by modified intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN 56877013. Findings 187 participants were randomised to the collaborative community-based care plus facility-based care group and 95 were randomised to the facility-based care alone group; 253 (90%) participants completed follow-up to month 12. At 12 months, total PANSS and IDEAS scores were lower in patients in the intervention group than in those in the control group (PANSS adjusted mean difference -3⋅75, 95% CI -7⋅92 to 0⋅42; p=0 08; IDEAS -0⋅95, -1⋅68 to -0⋅23; p=0⋅01). However, no difference was shown in the proportion of participants who had a reduction of more than 20% in overall symptoms (PANSS 85 [51%] in the intervention group vs 44 [51%] in the control group; p=0⋅89; IDEAS 75 [48%] vs 28 [35%]). We noted a significant reduction in symptom and disability outcomes at the rural Tamil Nadu site (-9⋅29, -15⋅41 to -3⋅17; p=0⋅003). Two patients (one in each group) died by suicide during the study, and two patients died because of complications of a road traffic accident and pre-existing cardiac disease. 18 (73%) patients (17 in the intervention group) were admitted to hospital during the course of the trial, of whom seven were admitted because of physical health problems, such as acute gastritis and vomiting, road accident, high fever, or cardiovascular disease. Interpretation The collaborative community-based care plus facility-based care intervention is modestly more effective than facility-based care, especially for reducing disability and symptoms of psychosis. Our results show that the study intervention is best implemented as an initial service in settings where services are scarce, for example in rural areas. INSET: Panel 2: Research in context. [ABSTRACT FROM AUTHOR]

The article presents the cross-sectional survey which determined the global pattern of experienced and anticipated discrimination reported by individuals with major depressive disorder. It examines whether experienced discrimination is linked to clinical history, provision of health care, and disclosure of diagnosis. It cites that depression is the third major contributor to the worldwide burden of disease.

The article offers information on the need to increase mental health services in low-income and middle-income countries. It mentions the barriers that prevent the increase of mental health services which include low priority in mental health of the people, scarcity of human and financial resources, and poor services. It argues the need to prioritize mental health and increase specialist mental health staff.

The authors discuss the opportunities for innovation in mental health systems in emerging economies including Brazil, Russia, India, China, and South Africa (BRICS). Topics discussed include the need to balance protection of services, the risks and opportunities for innovation through austerity, and the factors in psychosocial care networks in BRICS including embedded services in communities, specialised workers, and task-sharing.