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REDUCTIONOFMENTALHEALTHRELATED

STIGMAANDDISCRIMINATION:

GLOBALOVERVIEW

December2024

WorldBankGroup

MinistryofHealthandWelfareoftheRepublicofKorea

NationalCenterforMentalHealthoftheRepublicofKorea

©2024/TheWorldBank

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Acknowledgements

ThisreportwasledbySheilaDutta(SeniorHealthSpecialist,HAEH2)andKateMandeville(SeniorHealthSpecialist,HEAH2).TheauthorsareGrahamThornicroft(CentreforGlobalMentalHealthandCentreforImplementationScience,InstituteofPsychiatry,PsychologyandNeuroscience,King’sCollegeLondon),SueBaker,(ChangingMindsGlobally),PetraC.Gronholm(CentreforGlobalMentalHealthandCentreforImplementationScience,InstituteofPsychiatry,PsychologyandNeuroscience,King’sCollegeLondon),ClaireHenderson(CentreforImplementationScience,InstituteofPsychiatry,PsychologyandNeuroscience,King’sCollegeLondon),AhramHan(Consultant,ITSTI),SujinYang(Director,NationalCenterofMentalHealth),andYoung-sookKwak(President,NationalCenterofMentalHealth).

Theauthorswouldliketothankallthecontributorstothecountrycasestudies,includingShreyaRaoandShaquilleGraham(NōkuteAo,NewZealand),MichealPietrus(WorkingMindsprogramme/OpeningMinds,Canada),RobertO'LearyandGenesisLindstrom(batyr,Australia),SoseiYamaguchi,DaisukeNishi,NaoakiKuroda,AiAoki(MentalHealthSupporterTrainingProgramme,Japan),CarolLiang,OdileThiangandCandicePowell(MoreThanALabel,HongKong),ElaineLoo,PoojaNairandLiSanTan(BeyondtheLabel,Singapore).

ThisworkwasconductedunderthegeneralguidanceofMaraWarwick(CountryDirector,EACMK),JasonAllford(WorldBankGroupSpecialRepresentative,CEA10),RonaldMutasa(PracticeManager,HEAH1),CarynBredenkamp(PracticeManager,HEAH2),andMariaAnaLugo(LeadEconomistandProgramLeader(HEADR).

ThereportwaseditedandformattedbyPriyaThomasandSusiVictor.

ThisworkwasfundedbytheMinistryofEconomicsandFinanceandreviewedbytheMinistryofHealthandWelfare,RepublicofKorea.ThisworkwouldnothavebeenpossiblewiththesupportoftheWorldBankGroupKoreaOffice.

TableofContents

1.EXECUTIVESUMMARY 1

2.THEIMPORTANCEOFSTIGMAANDDISCRIMINATIONINMENTALHEALTH 3

3.DEFININGSTIGMAANDDISCRIMINATION 4

3.1.Publicstigma 4

3.2.Self-stigma 4

3.3.Familystigma 5

3.4.Structuralstigma 5

4.EVIDENCEONHOWTOREDUCEMENTALHEALTHSTIGMAANDDISCRIMINATION 6

4.1.Methods 6

4.2.Structuralstigma 6

4.3.Publicstigma 9

4.4.Specificinterventioncomponents 15

4.5.Self-stigma 17

4.6.Cost-effectiveness 19

5.OVERVIEWOFCASESTUDIESOFNATIONAL-LEVELANTI-STIGMAPROGRAMS 20

6.CONCLUSIONSANDRECOMMENDATIONS 32

APPENDIX1.REFERENCES 33

APPENDIX2.DETAILEDCASESTUDIESOFNATIONALANTI-STIGMAPROGRAMS 47

1.‘TimetoChange’program,England 47

2.NōkuteAooprogram(previouslycalledLikeMinds,LikeMine),NewZealand 50

3.batyrprogram,Australia 52

4.TimetoChangeGlobalprogram,AfricaandIndia 55

5.UnderstandingStigmaandStrengtheningCognitiveBehavioralInterpersonalSkillsprogram,the

Caribbean 58

6.NAROVINU(OntheLevel)program,CzechRepublic 59

7.WorkingMindsprogram,Canada 61

8.MoreThanaLabelprogram,HongKong 64

9.MentalHealthSupporterTrainingprogram,Japan 66

10.‘BeyondtheLabel’program,Singapore 68

ReductionofMentalHealthRelatedStigmaandDiscrimination:GlobalOverview

Acronyms

BNBR

BTL

CAMI

CBM

CCBC

CINAHL

DISC

ERIC

FCDOFGD

GKT

IOPPNKCL

LMIC

MAKSMATESMH

MHFANCSSNGO

NIMHCZOMS-HC

PMHCRIBS

R2MRSROISSCITLC3TTC

TTCGTIM

TWMWHO

BasicNeedsBasicRightsBeyondtheLabel

CommunityAttitudesonMentalIllnessScaleChristianBlindnessMission

CollaborativeCommunity-BasedCare

CumulativeIndextoNursingandAlliedHealthDiscriminationandStigmaScale

EducationResourcesInformationCenter

Foreign,CommonwealthandDevelopmentOffice

FocusGroupDiscussionGatekeeperTraining

InstituteofPsychiatry,PsychologyandNeuroscienceKing’sCollegeLondon

Low-andMiddle-IncomeCountryMentalHealthKnowledgeScale

MatesinConstructionProgrammeMentalHealth

MentalHealthFirstAid

NationalCouncilofSocialServiceNongovernmentalOrganization

NationalInstituteofMentalHealth,Czechia

OpeningMindsStigmaScaleforHealthCareProvidersPeoplewithMentalHealthConditions

ReportedandIntendedBehaviourScale

RoadtoMentalReadiness

SocialReturnOnInvestmentSocialScienceCitationIndex

Targeted,Local,Credible,ContinuousContact

TimetoChange

TimetoChangeGlobalTheInquiringMind

TheWorkingMind

WorldHealthOrganization

ReductionofMentalHealthRelatedStigmaandDiscrimination:GlobalOverview

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1.EXECUTIVESUMMARY

Stigmaanddiscriminationcontravenebasichumanrightsandhavedetrimentaleffectsonpeoplewithmentalhealthconditionsbyexacerbatingmarginalizationandsocialexclusion—includingbyreducingaccesstomentalandphysicalhealthcareanddiminishingeducationalandemploymentopportunities.Thestigmaanddiscriminationsurroundingmentalhealthhavenegativeconsequencesforsocialexclusioninrelationtoeducation,theworkplace,andthecommunity,aswellasformaritalprospects,lossofproperty,inheritance,orrightstovote,andpoorqualityhealthcareformentalandphysicalhealthconditions.Stigmapowerfullyandadverselyaffectsindividuals,families,communities,andsociety,andexistsacrossallcountriesandcultures.Arecentglobalsurveyofpeoplewithmentalhealthconditionsacross45countriesfoundthat80percentagreedthat“stigmaanddiscriminationcanbeworsethattheimpactofthementalhealthconditionitself.”

Theoverallobjectiveofthispolicynote,preparedjointlybytheWorldBankGroupandKoreanNationalCenterforMentalHealth,istosummarizeglobalevidenceforeffectiveinterventionstoreducementalhealth-relatedstigmaanddiscrimination.Thefirstsectionofthisreportdefinesstigmaanddiscrimination,describestheadverseimpactonthelivesofpeoplewithmentalhealthconditions,andsummarizesresultsofanarrativeliteraturereviewoftheevidencebaseforinterventionsaddressingmentalillness-relatedstigmaanddiscrimination.Thisreportinvolvedasynthesisofover260systematicreviewsonstigmareductionandpresentsadetailedsummaryoftheglobalevidenceonhowtoreducestigmaanddiscrimination(buildingonearlierfindingsoftheLancetCommissiononEndingStigmaandDiscriminationinMentalHealth).Thisreviewexaminedevidenceregardinginterventionimpactsandsummarizeskeyfindings.Notably,thisglobalreviewindicatesthatinterventionsbasedontheprincipleofsocialcontact(whetherinperson,virtual,orindirect),thathavebeenappropriatelyadaptedtodifferentcontextsandcultures,arethemosteffectivewaystoreducestigmatizationworldwide.

Globalexperience,overthepast25years,demonstratesthatitisfeasibletoscaleupanti-stigmaprogramstothenationalleveltoeffectivelyreducestigmaanddiscriminationinlarge-scalepopulations.Consequently,thesecondsectionofthisreportfocusesonexaminingimplementationexperiencesofdeliveringanti-stigmaanddiscriminationprogramsandincludescasestudiesthathavedevelopedeffectiveandevidence-basedinitiatives.Thesecasestudieswereselectedpurposivelytoenablerepresentationofdifferenttypesofanti-stigmaandanti-discriminationinterventions,acrossarangeofgeographical/culturalcontextsanddiversetargetgroups.

Thesepurposivelyselectedcasestudiessummarizehowprogramsweredesigned,implemented,evaluated,andscaledup.Thecasestudiesdemonstratehowevidence-basedprinciplesforanti-stigmainterventionscanbeadaptedandputintoeffectivepracticeinarangeofcountriesandcontextsandculturesacrosstheworld.Althoughstigmaanddiscriminationstillseemtobeoneofthemostneglectedaspectsofmentalhealth,asthesecasestudiesshow,insomecountriestherehadbeenasignificantshiftwiththetransformationofmentalhealthpolicyleadingtothewelcometransitionofservicesfrominstitution-basedcaretocommunity-basedcareandsupport.However,theneedtoeducatecommunitiesandtransformattitudes,tocreatemoresupportiveandinclusivecommunitiesandultimatelysupportrecoverybeyondtheprovisionoftreatmentofsymptoms,isoftenoverlooked.

TheCOVID-19erahasincreasedawarenessoftheneedforprogramsthatchallengementalhealthstigmaandsupportearlierhelp-seekingandself-care.Ashighlightedinthisanalysis,mostofthecasestudyprogramshaveadaptedglobalevidence-basedmethods—withmanypositiveimpactsreportedandmuchlearningtoshare.Somekeycomponentsincludesocialcontact,livedexperiencechampions/ambassadorstosharetheirmentalhealthexperiencesatsocialcontacteventsandonline,socialmarketingcampaigns,targetedprogramswithhealthcareprofessionals,employers,schools,

ReductionofMentalHealthRelatedStigmaandDiscrimination:GlobalOverview

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universitiesandyouthaudiences,andthemedia.Specificlessonsderivedfromthecasestudiesincludethefollowing:

•Socialcontactshouldbeimplementedwithcontextualandculturaladaptationtoeachsetting.Socialcontactcanbeeffectiveeitherdelivereddirectly(inperson)orindirectly(usingremote,digital,andonlinemethods).Additionally,theevidenceforsocialcontactimpliesthatthedirectinvolvementofpeoplewithlivedexperienceofmentalhealthconditions,inco-leadingtheprogramdesign,delivery,andevaluation,isnecessary.

•Long-termprogramsarenecessaryforsustainablestigmareduction.

•Impactcanbeassessedbyevaluatingtheprogram,byestablishingabaselineassessmentbeforetheprogramstarts,followedbyperiodicassessmentsofprogresstostigmareduction.

•Reducingstigmacanleadtoincreasedhelp-seekingbypeoplewithmentalhealthconditions.

•Betteraccesstocareforpeoplewithmentalhealthconditionsisexpectedtoleadtoshorterdurationofsymptomsanddisability,greatereducationalattainment,lowersuiciderates,lesspresenteeismandabsenteeismintheworkplace,andgreaterproductivityforpeoplewhosementalhealthconditionshavebeentreatedearlyandwell.

Thisbriefingpaperproposesthefollowingspecificrecommendations:

1.Plansmustbecreatedtofund,implement,andevaluatelong-termprogramstoreducementalhealthstigmaanddiscrimination.

2.Thecentralcomponentoftheseplansistousetheevidence-basedactiveingredientofsocialcontactforstigmareduction.

3.Peoplewithafullrangeofmentalhealthconditions,includingmoresevereconditions,needtoactivelycontributetotheseplansbyco-leadingthedesign,delivery,andevaluationoftheprograms.

4.Specifickeytargetaudiencesandoutcomesneedtobeidentifiedattheoutsetofeachprogram.

5.Theprogramsmustoperatewithwidespreadcross-sectoralsupportandparticipation,forexamplewiththeindustry,sports,music,television,film,healthcare,andeducationalsectors.

Adetailedevaluationofimpactsandoutcomesmustbeconductedforeachprogramandcomparedwithaninitialbaselineassessmentofkeymetrics.

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2.THEIMPORTANCEOFSTIGMAANDDISCRIMINATIONINMENTALHEALTH

Thestigmaanddiscriminationwithregardtomentalhealthhavenegativeconsequencesforsocialexclusioninrelationtomaritalprospects,education,theworkplace,andthecommunity;lossofproperty,inheritance,orrightstovote;andpoor-qualityhealthcareformentalandforphysicalhealthconditions.Stigmapowerfullyandadverselyaffectsindividuals,families,communities,andsociety,andexistsacrossallcountriesandcultures.Theseperniciousbarrierstofullcitizenshipandsocialparticipationshareonefundamentalcharacteristic—theycontravenebasichumanrightswhichareintendedtoapplyequallytoeveryone.Indeed,arecentglobalsurveyof391peoplewithmentalhealthconditionsfrom45countriesworldwidefoundthat80percentagreedthat“stigmaanddiscriminationcanbeworsethattheimpactofthementalhealthconditionitself”(Thornicroftetal.2022).

ThisWorldBankpolicynoteisstructuredasfollows.First,theterms‘stigma’and‘discrimination’aredefined.Thenextsectiondescribeshowstigmaanddiscriminationadverselyaffectthelivesofpeoplewithmentalhealthconditions—amoredetailedaccountwaspublishedinTheLancetCommissiononEndingStigmaandDiscriminationinMentalHealth(Thornicroftetal.2022).Adetailedsummaryoftheglobalevidenceonhowtoreducestigmaanddiscriminationispresentedhere,whichsummarizesandupdatestheevidencesynthesisoftheLancetCommission.ItwouldbeusefultoreadthisreportincloseconjunctionwiththeLancetCommissionreport.Wehaveconsideredpracticalcasestudyexamplesthatdemonstratehowtheseevidence-basedprinciplesforanti-stigmainterventionscanbeadaptedandputintopracticeinarangeofcountries,contexts,andculturesacrosstheworld.Thisbriefingnotecloseswithaseriesofrecommendationswhichareintendedfordiscussionandelaborationintermsoftheirrelevanceandapplicabilityindifferentcontexts.

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3.DEFININGSTIGMAANDDISCRIMINATION

Stigmaanddiscriminationcanbedefinedintermsoffourcomponents,asshowninFigure1.ThetermstigmastemsfromancientGreekandoriginallyreferredtoatattoo,whichwasusedtovisiblymarkslavesorcriminalsasmembersofsocietywithadiminishedvalue(Thornicroftetal.2022).Inthesocialsciences,thetermstigmawaselaboratedinthesecondhalfofthetwentiethcenturybyGoffman(1963),whodefinedstigmaasa‘deeplydiscrediting’attributewhichreducesaperson“fromawholeandusualpersontoatainteddiscountedone.”Aseparationisthereforecreatedbetween‘us’and‘them’,basedonthebeliefthatthelabelledpeoplearefundamentallydifferentfrom,andoflowervaluethan,otherpeople.Discriminationistheunfairtreatmentofapersonoragroupofpeoplebecauseofaparticularcharacteristic,suchaspeoplewhohavelivedexperienceofmentalhealthconditions.Thestigmatizationofpeoplewithmentalhealthconditionsneedstobeconsideredwithinthebroaderframeworksofjustice,socialequity,andhumanrights.

Figure1.Typesofstigma

Familystigma

3.1.Publicstigma

Publicstigmahasthreecomponents:knowledge,attitudes,andbehaviors.Theknowledgecomponentusuallyreferstoalackofknowledgeinpopulationsaboutmentalhealthconditions(ignorance)andtomisinformationthatisoftenfoundinpopulardiscourseandispartoflocalbeliefs.Suchmisconceptionsinclude,forexample,beliefsaboutthedangerousnessorincompetenceofpeoplewithmentalhealthconditions,orthebeliefthatsuchconditionscannotbetreated,orareduetoacurse(Corriganetal.2003).Attitudesreferalmostentirelytothenegativeemotionalreactionsofpeopleinthegeneralpopulationtowardpeoplewithmentalhealthconditions,suchasfearordisgust.Behaviorreferstotherejectionandsocialexclusionofpeoplewithmentalhealthconditions,namelydiscrimination(Pescosolidoetal.2013;Thornicroft,Rose,andKassam2007).

3.2.Self-stigma

Self-stigma,orinternalizedstigma,occurswhenpeoplewithmentalhealthconditionsareawareofthenegativestereotypesofothers,agreewiththem,andturntheminwardsagainstthemselves.

Theinternalizationofnegativebeliefscanleadtodiminishedself-esteemandself-efficacy,anda‘why

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try’effect.Thisoccurswhenpeoplewithmentalhealthconditionsgiveupimportantlifegoals,suchasseekingajoborengaginginfriendships,becausetheyfeeltheywillnotbeabletosucceed(CorriganandWatson2006).

3.3.Familystigma

Familystigmaisalsoknownas‘stigmabyassociation’,‘courtesystigma’,or‘affiliatestigma’.Thisreferstostigmaanddiscriminationasexperiencedbyfamilymembers,aswellasmentalhealthstaff,thatis,peoplewhoareinclosecontactwithpeoplewithmentalhealthconditions.Suchstigmaseemstodependonthetypeofcondition.Ifamentalhealthconditionisconsideredhereditary,orduetokarma,thiscanincurlossoffaceandgreaterstigma(MakandCheung2012).Similarly,conditionsthatarebelievedtoadverselyaffectmaritalprospectscanalsodamagethereputationoffamilymembersofpeoplewithmentalhealthconditions(Shietal.2019).Itisalsocommonforstaffworkinginphysicalhealthcaresettingstohavenegativeattitudestowardstaffwhoworkinmentalhealthsettings,whichareseenaslessprestigious,forexample,withinthefieldofmedicine.

3.4.Structuralstigma

Structuralstigma(alsocalledsystemicorinstitutionalstigma)referstopoliciesandpracticesthatworktothedisadvantageofpeoplewithmentalhealthconditions.Structuralstigmahasbeendefinedas“societal-levelconditions,culturalnorms,andinstitutionalpoliciesthatconstraintheopportunities,resources,andwellbeingofthestigmatized”(HatzenbuehlerandLink2014).Stigmaisoftenseenasabarriertopolicychange.Itcanplayoutinalackofpublicdemandforgovernmentalactionandinvestmentandinmisinformation,misunderstandingandlackofawarenessofpositivepolicyoptionsamongpolicymakers.Furtherexamplesofstructuralstigmaincludethefactthatpeoplewithmentalhealthconditionscommonlyexperiencerestrictionsinemployment,voting,propertyownership,marriage,anddivorce(Thornicroft2006).Anotheraspectofstructuralstigmarelatestolowlevelsoffinancialandhumanresources,sincefewerresourcesareallocatedtoresearchandtreatmentformentalhealththanforphysicalconditions(Chisholmetal.2019).Animportantconsequenceofstructuralstigmaisthatworldwide,mostpeoplewithmentalhealthconditionsdonotreceivetreatment.Fordepressionandanxiety,forexample,thistreatmentgapisestimatedtobeabout95percentinlow-incomecountries,90percentinmiddle-incomecountries,and70–80percentinhigh-incomecountries(Thornicroftetal.2017).Inaddition,peoplewithmentalhealthconditionshavelessaccesstohealthcareingeneral,andreceivepoorerqualityofservices,whichleadstoa10-yearmortalitygapforallpeoplewithmentalhealthconditions,anda20-yearmortalitygapforpeoplewithseverementalhealthconditions(Walker,McGee,andDruss2015).

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4.EVIDENCEONHOWTOREDUCEMENTALHEALTHSTIGMAANDDISCRIMINATION

4.1.Methods

Weconductedareviewofsystematicreviewsofinterventionsintendedtoreducestigma.Wesearchedsevendatabases(PsycInfo,Medline,EMBASE,CumulativeIndextoNursingandAlliedHealth(CINAHL),EducationResourcesInformationCenter[ERIC],GlobalHealth,SocialScienceCitationIndex[SSCI])forEnglishlanguageliteraturereviews.SearcheswererunonDecember12and15,2021,fortheLancetCommissiononEndingStigmaandDiscriminationinMentalHealth(Thornicroftetal.2022)andupdatedonApril14and16,2024(alldatabasesexceptSSCI).Thesearchincludedfourconcepts:stigmaanddiscrimination,interventions,review,andmentalhealthconditions.Individualsearchstrategiesincludingspecificsubjectheadingsweredevelopedforeachdatabase.ThisreviewthereforeincludesandupdatestheLancetCommissionumbrellareview.

Anyreview(systematic,meta-analysis,scoping,rapid,umbrella,ornarrative)waseligibleforinclusion.Reviewswereincludediftheyappraisedqualitativeorquantitativefindingsofinterventionswhichaimedtoreducestigmainrelationtoamentalhealthcondition.Allcountriesandagegroupswereincluded.Interventionswereincludedifastigmaorstigma-relatedoutcome(forexample,attitudes,beliefs,knowledge,mentalhealthliteracy,socialinclusion)waseithertheprimaryorsecondaryoutcome.TheumbrellareviewwasregisteredwithProspero,registrationnumberCRD42022299682.Thesearchesyielded21,180entries.Afterremoving9,526duplicates,11,654titlesorabstractswerescreened.Irrelevantstudies(n=11,151)wereexcluded,and503fulltextswereassessedforeligibility.Atotalof267reviewswereincluded,notallofwhicharecitedduetosomebeingoflowerqualityaswellasoverlapintheincludedstudies,andhencetheconclusionsdrawn.Herewesummarizethefindingsforstructural,interpersonal,andself-stigma.

4.2.Structuralstigma

4.2.1Policies

Afewreviewstargetedpolicies.IdentifiedstudiesinvestigatedtheimpactofvariousprofessionalandpublicinitiativestoreducestigmaanddiscriminationagainstpeoplewithdepressioninSlovenia(Valic,Knifton,andSvab2013)andcasestudiesondismantlingmentalhealthandsubstanceuserelatedstructuralstigmainCanadianhealthcaresettings(SukheraandKnaak2022).Theincludedstudiesfoundpositiveoutcomesfromreducingstructuralstigmathroughpolicies;however,thequalityofmanystudieswaslow.Policiesaimingtoestablishrespecttowardpeoplewithmentalhealthconditionsandstipulatingtheirrightsontheirownfallshortineffectivelyreducingdiscrimination.

Moreeffectivepolicies,legislation,andplanswereoftenlinkedwithcommunity-basedtreatment,programsforpubliceducation,andmediaactivitiesincludingparticipationof‘champions’withlivedexperienceofmentalhealthconditionsandchangingpowerrelationshipstoallowsharedunderstandingoftheproblemandalignmentofvalues.TheCanadianexemplarsshowedpromiseinimprovingaccess,healthquality,andoutcomesrelatedtoreducedcoercion,andpolicyandpracticechange.Thisrequiredmanagingresistanceproactively,embracingdisruptiveinnovation,andfosteringtrustthroughdialogue.SeveralnationalprogramsagainststigmaanddiscriminationinAsiawerefoundtoreduceexperiencedandanticipatedstigmaamongpeoplewithmentalhealthconditionsandtofacilitatehelp-seekingandengagementwithmentalhealthcare,yetnodatawereavailableonwhethertheyhadactuallyincreasedaccesstomentalhealthcare.Thepotentialimpactofpolicyinterventionstargetingstructuralstigmaishigh,however,moreresearchisneededontheirculturalsensitivity,effectiveness,andcost-effectiveness.

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InsomeEastAsiancountries,usingadifferenttermforschizophreniawasusedasastrategytoreducepublicstigma.Thereissomeevidencethatafterthenamechangemorepeoplewithschizophreniawereinformedabouttheirdiagnosis(Yamaguchietal.2017).However,thereisnoevidenceforpositiveeffectsonpublicattitudesormediareporting(Corrigan2018).Itislikelytobehelpfulifdiagnostictermswhichcauseoffensearerevisedwiththeinvolvementofpeoplewhohavebeengiventhesediagnoses.Effectiveeffortstoaddressstructuralstigmaatthepolicylevelhavealsoincludednationalmentalhealthplansandpoliciesandanti-discriminationlawstoprotecttherightsandinterestsofpeoplewithmentalhealthconditionsincare,atwork,andinwidersociety.Coalitionsofstakeholders,oftenledbynongovernmentalorganizations(NGOs),mentalhealthassociations,andmentalhealthprofessionals,withtheparticipationofempoweredpeoplewithlivedexperience,haveplayedkeyroles