Impact of Service User Video Presentations on Explicit and Implicit Stigma toward Mental Illness among Medical Students in Nepal: A Randomized Controlled Trial

Cori L Tergesen, Dristy Gurung, Saraswati Dhungana, Ajay Risal, Prem Basel, Dipesh Tamrakar, Archana Amatya, Lawrence P Park, Brandon A Kohrt, Cori L Tergesen, Dristy Gurung, Saraswati Dhungana, Ajay Risal, Prem Basel, Dipesh Tamrakar, Archana Amatya, Lawrence P Park, Brandon A Kohrt

Abstract

This study evaluated the impact of didactic videos and service user testimonial videos on mental illness stigma among medical students. Two randomized controlled trials were conducted in Nepal. Study 1 examined stigma reduction for depression. Study 2 examined depression and psychosis. Participants were Nepali medical students (Study 1: n = 94, Study 2: n = 213) randomized to three conditions: a didactic video based on the mental health Gap Action Programme (mhGAP), a service user video about living with mental illness, or a control condition with no videos. In Study 1, videos only addressed depression. In Study 2, videos addressed depression and psychosis. In Study 1, both didactic and service user videos reduced stigma compared to the control. In Study 2 (depression and psychosis), there were no differences among the three arms. When comparing Study 1 and 2, there was greater stigma reduction in the service user video arm with only depression versus service user videos describing depression and psychosis. In summary, didactic and service user videos were associated with decreased stigma when content addressed only depression. However, no stigma reduction was seen when including depression and psychosis. This calls for considering different strategies to address stigma based on types of mental illnesses. ClinicalTrials.gov identifier: NCT03231761.

Keywords: attitudes; depression; developing countries; medical education; mental health; psychosis; service users; stigma.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
CONSORT flow diagram for research procedures in Study 1 (depression only). Note: in the service user video study arm, one participant excluded at the analysis phase met both the psychiatry rotation and international exclusion criteria. Abbreviations: MBBS, Bachelors of Medicine, Bachelors of Surgery.
Figure 2
Figure 2
Second- and third-year medical students expressed interest in specific medical specialties (n = 94). Answers were selected from a multiple-choice question of common specialties offered in Nepali medical school.
Figure 3
Figure 3
CONSORT participant flow diagram for research procedures in Study 2 (depression and psychosis). Abbreviations: MBBS—Bachelors of Medicine, Bachelors of Surgery.
Figure 4
Figure 4
Social distance towards mental illness among second-year medical students at Tribhuvan University in Study 1 (depression only, n = 45) vs. second-year medical students at Tribhuvan University in Study 2 (depression and psychosis, n = 51).

References

    1. Henderson C., Noblett J., Parke H., Clement S., Caffrey A., Gale-Grant O., Schulze B., Druss B., Thornicroft G. Mental health-related stigma in health care and mental health-care settings. Lancet Psychiatry. 2014;1:467–482. doi: 10.1016/S2215-0366(14)00023-6.
    1. Thornicroft G., Rose D., Kassam A. Discrimination in health care against people with mental illness. Int. Rev. Psychiatry. 2007;19:113–122. doi: 10.1080/09540260701278937.
    1. Suwalska J., Suwalska A., Neumann-Podczaska A., Łojko D. Medical students and stigma of depression. Part I. Stigmatization of patients. Psychiatr. Pol. 2017;51:495–502. doi: 10.12740/PP/OnlineFirst/63515.
    1. Stefanovics E., He H., Ofori-Atta A., Cavalcanti M.T., Neto H.R., Makanjuola V., Ighodaro A., Leddy M., Rosenheck R. Cross-national analysis of beliefs and attitude toward mental illness among medical professionals from five countries. Psychiatr. Q. 2016;87:63–73. doi: 10.1007/s11126-015-9363-5.
    1. Economou M., Peppou L., Geroulanou K., Kontoangelos K., Prokopi A., Pantazi A., Zervakaki A., Stefanis C. Attitudes of psychology students to depression and its treatment: Implications for clinical practice. Psychiatrike. 2017;28:46. doi: 10.22365/jpsych.2017.281.46.
    1. Fernando S.M., Deane F.P., McLeod H.J. Sri Lankan doctors’ and medical undergraduates’ attitudes towards mental illness. Soc. Psychiatry Psychiatr. Epidemiol. 2010;45:733–739. doi: 10.1007/s00127-009-0113-6.
    1. Lyons Z., Janca A. Impact of a psychiatry clerkship on stigma, attitudes towards psychiatry, and psychiatry as a career choice. BMC Med. Educ. 2015;15:34. doi: 10.1186/s12909-015-0307-4.
    1. Poreddi V., Thimmaiah R., Math S.B. Attitudes toward people with mental illness among medical students. J. Neurosci. Rural Pract. 2015;6:349.
    1. Prathaptharyan T.J., Annatharyan D. Attitudes of ’tomorrow’s doctors’ towards psychiatry and mental illness. Natl. Med. J. India. 2001;14:355–359.
    1. Giasuddin N.A., Levav I., Gal G. Mental health stigma and attitudes to psychiatry among bangladeshi medical students. Int. J. Soc. Psychiatry. 2015;61:137–147. doi: 10.1177/0020764014537237.
    1. Korszun A., Dinos S., Ahmed K., Bhui K. Medical student attitudes about mental illness: Does medical-school education reduce stigma? Acad. Psychiatry. 2012;36:197–204. doi: 10.1176/appi.ap.10110159.
    1. Aydin N., Yigit A., Inandi T., Kirpinar I. Attitudes of hospital staff toward mentally ill patients in a teaching hospital, Turkey. Int. J. Soc. Psychiatry. 2003;49:17–26. doi: 10.1177/0020764003049001544.
    1. Griffiths K.M., Carron-Arthur B., Parsons A., Reid R. Effectiveness of programs for reducing the stigma associated with mental disorders. A meta-analysis of randomized controlled trials. World Psychiatry. 2014;13:161–175. doi: 10.1002/wps.20129.
    1. Mehta N., Clement S., Marcus E., Stona A.-C., Bezborodovs N., Evans-Lacko S., Palacios J., Docherty M., Barley E., Rose D. Evidence for effective interventions to reduce mental health-related stigma and discrimination in the medium and long term: Systematic review. Br. J. Psychiatry. 2015;207:377–384. doi: 10.1192/bjp.bp.114.151944.
    1. Corrigan P.W., Kerr A., Knudsen L. The stigma of mental illness: Explanatory models and methods for change. Appl. Prev. Psychol. 2005;11:179–190. doi: 10.1016/j.appsy.2005.07.001.
    1. Corrigan P.W., Morris S.B., Michaels P.J., Rafacz J.D., Rusch N. Challenging the public stigma of mental illness: A meta-analysis of outcome studies. Psychiatr. Serv. 2012;63:963–973. doi: 10.1176/appi.ps.201100529.
    1. Yamaguchi S., Wu S.I., Biswas M., Yate M., Aoki Y., Barley E.A., Thornicroft G. Effects of short-term interventions to reduce mental health-related stigma in university or college students: A systematic review. J. Nerv. Ment. Dis. 2013;201:490–503. doi: 10.1097/NMD.0b013e31829480df.
    1. Pettigrew T.F., Tropp L.R. A meta-analytic test of intergroup contact theory. J. Personal. Soc. Psychol. 2006;90:751. doi: 10.1037/0022-3514.90.5.751.
    1. Clement S., van Nieuwenhuizen A., Kassam A., Flach C., Lazarus A., de Castro M., McCrone P., Norman I., Thornicroft G. Filmed v. Live social contact interventions to reduce stigma: Randomised controlled trial. Br. J. Psychiatry. 2012;201:57–64. doi: 10.1192/bjp.bp.111.093120.
    1. Reinke R.R., Corrigan P.W., Leonhard C., Lundin R.K., Kubiak M.A. Examining two aspects of contact on the stigma of mental illness. J. Soc. Clin. Psychol. 2004;23:377–389. doi: 10.1521/jscp.23.3.377.35457.
    1. Papish A., Kassam A., Modgill G., Vaz G., Zanussi L., Patten S. Reducing the stigma of mental illness in undergraduate medical education: A randomized controlled trial. BMC Med. Educ. 2013;13:1–10. doi: 10.1186/1472-6920-13-141.
    1. Kassam A., Glozier N., Leese M., Loughran J., Thornicroft G. A controlled trial of mental illness related stigma training for medical students. BMC Med. Educ. 2011;11:51. doi: 10.1186/1472-6920-11-51.
    1. Heim E., Henderson C., Kohrt B.A., Koschorke M., Milenova M., Thornicroft G. Reducing mental health-related stigma among medical and nursing students in low- and middle-income countries: A systematic review. Epidemiol. Psychiatr. Sci. 2020;29:e28. doi: 10.1017/S2045796019000167.
    1. Iheanacho T., Marienfeld C., Stefanovics E., Rosenheck R.A. Attitudes toward mental illness and changes associated with a brief educational intervention for medical and nursing students in nigeria. Acad. Psychiatry. 2014;38:320–324. doi: 10.1007/s40596-014-0073-3.
    1. Altindag A., Yanik M., Ucok A., Alptekin K., Ozkan M. Effects of an antistigma program on medical students’ attitudes towards people with schizophrenia. Psychiatry Clin. Neurosci. 2006;60:283–288. doi: 10.1111/j.1440-1819.2006.01503.x.
    1. Fernandez A., Tan K.-A., Knaak S., Chew B.H., Ghazali S.S. Effects of brief psychoeducational program on stigma in malaysian pre-clinical medical students: A randomized controlled trial. Acad. Psychiatry. 2016;40:905–911. doi: 10.1007/s40596-016-0592-1.
    1. Jordans M.J.D., Luitel N.P., Kohrt B.A., Rathod S.D., Garman E.C., de Silva M., Komproe I.H., Patel V., Lund C. Community-, facility-, and individual-level outcomes of a district mental healthcare plan in a low-resource setting in Nepal: A population-based evaluation. PLoS Med. 2019;16:e1002748. doi: 10.1371/journal.pmed.1002748.
    1. Gartoulla P., Pantha S., Pandey R. Knowledge status on mental health among health professionals of chitwan district, Nepal. J. Inst. Med. 2015;37:91–97.
    1. Luitel N.P., Jordans M.J.D., Kohrt B.A., Rathod S.D., Komproe I.H. Treatment gap and barriers for mental health care: A cross-sectional community survey in Nepal. PLoS ONE. 2017;12:e0183223. doi: 10.1371/journal.pone.0183223.
    1. Luitel N., Jordans M., Adhikari A., Upadhaya N., Hanlon C., Lund C., Komproe I. Mental health care in Nepal: Current situation and challenges for development of a district mental health care plan. Confl. Health. 2015;9:3. doi: 10.1186/s13031-014-0030-5.
    1. World Health Organization . Mhgap Intervention Guide for Mental, Neurological and Substance Use Disorders in Non-Specialized Health Settings: Mental Health Gap Action Programme (MHGAP)—Version 2.0. World Health Organization; Geneva, Switzerland: 2016.
    1. Acharya B., Tenpa J., Basnet M., Hirachan S., Rimal P., Choudhury N., Thapa P., Citrin D., Halliday S., Swar S. Developing a scalable training model in global mental health: Pilot study of a video-assisted training program for generalist clinicians in rural Nepal. Glob. Ment Health. 2017;4:41. doi: 10.1017/gmh.2017.4.
    1. Rai S., Gurung D., Kaiser B.N., Sikkema K.J., Dhakal M., Bhardwaj A., Tergesen C., Kohrt B.A. A service user co-facilitated intervention to reduce mental illness stigma among primary healthcare workers: Utilizing perspectives of family members and caregivers. Fam. Syst. Health. 2018;36:198–209. doi: 10.1037/fsh0000338.
    1. Kohrt B.A., Jordans M.J.D., Turner E.L., Sikkema K.J., Luitel N.P., Rai S., Singla D.R., Lamichhane J., Lund C., Patel V. REducing Stigma among Healthcare ProvidErs to improve mental health services (RESHAPE): Protocol for a pilot cluster randomized controlled trial of a stigma reduction intervention for training primary healthcare workers in Nepal. Pilot Feasibility Stud. 2018;4:36. doi: 10.1186/s40814-018-0234-3.
    1. Kohrt B.A., Turner E.L., Rai S., Bhardwaj A., Sikkema K.J., Adelekun A., Dhakal M., Luitel N.P., Lund C., Patel V., et al. Reducing mental illness stigma in healthcare settings: Proof of concept for a social contact intervention to address what matters most for primary care providers. Soc. Sci. Med. 2020;250:112852. doi: 10.1016/j.socscimed.2020.112852.
    1. Kaiser B.N., Varma S., Carpenter-Song E., Sareff R., Rai S., Kohrt B.A. Eliciting recovery narratives in global mental health: Benefits and potential harms in service user participation. Psychiatr. Rehabil. J. 2020;43:111–120. doi: 10.1037/prj0000384.
    1. Lund C., Tomlinson M., De Silva M., Fekadu A., Shidhaye R., Jordans M., Petersen I., Bhana A., Kigozi F., Prince M., et al. Prime: A programme to reduce the treatment gap for mental disorders in five low- and middle-income countries. PLoS Med. 2012;9:e1001359. doi: 10.1371/journal.pmed.1001359.
    1. Jordans M.J.D., Luitel N.P., Pokhrel P., Patel V. Development and pilot testing of a mental healthcare plan in Nepal. Br. J. Psychiatry. 2015;208:S21–S28. doi: 10.1192/bjp.bp.114.153718.
    1. Acharya B., Basnet M., Rimal P., Citrin D., Hirachan S., Swar S., Thapa P., Pandit J., Pokharel R., Kohrt B. Translating mental health diagnostic and symptom terminology to train health workers and engage patients in cross-cultural, non-english speaking populations. Int. J. Ment. Health Syst. 2017;11:62. doi: 10.1186/s13033-017-0170-2.
    1. Kohrt B.A., Hruschka D.J. Nepali concepts of psychological trauma: The role of idioms of distress, ethnopsychology and ethnophysiology in alleviating suffering and preventing stigma. Cult. Med. Psychiatry. 2010;34:322–352. doi: 10.1007/s11013-010-9170-2.
    1. Kohrt B.A., Harper I. Navigating diagnoses: Understanding mind-body relations, mental health, and stigma in Nepal. Cult. Med. Psychiatry. 2008;32:462–491. doi: 10.1007/s11013-008-9110-6.
    1. Pescosolido B.A., Long J.S., Martin J.K., Smith T. Stigma & Mental Illness in Cross-National Perspective: The Sgc-Mhs Interview Schedule Final Revision (Summer 2004) Indiana University; Bloomington, IN, USA: 2004.
    1. Pescosolido B.A., Medina T.R., Martin J.K., Long J.S. The “backbone” of stigma: Identifying the global core of public prejudice associated with mental illness. Am. J. Public Health. 2013;103:853–860. doi: 10.2105/AJPH.2012.301147.
    1. Bogardus E.S. Measuring social distance. J. Appl. Sociol. 1925;9:299–308.
    1. Van Brakel W.H., Cataldo J., Grover S., Kohrt B.A., Nyblade L., Stockton M., Wouters E., Yang L.H. Out of the silos: Identifying cross-cutting features of health-related stigma to advance measurement and intervention. BMC Med. 2019;17:13. doi: 10.1186/s12916-018-1245-x.
    1. Greenwald A.G., McGhee D.E., Schwartz J.L. Measuring individual differences in implicit cognition: The implicit association test. J. Personal. Soc. Psychol. 1998;74:1464. doi: 10.1037/0022-3514.74.6.1464.
    1. Peris T.S., Teachman B.A., Nosek B.A. Implicit and explicit stigma of mental illness: Links to clinical care. J. Nerv. Ment. Dis. 2008;196:752–760. doi: 10.1097/NMD.0b013e3181879dfd.
    1. Greenwald A.G., Nosek B.A., Banaji M.R. Understanding and using the implicit association test: I. An improved scoring algorithm. J. Personal. Soc. Psychol. 2003;85:197. doi: 10.1037/0022-3514.85.2.197.
    1. Jordans M.J., Kohrt B.A., Luitel N.P., Komproe I.H., Lund C. Accuracy of proactive case finding for mental disorders by community informants in Nepal. Br. J. Psychiatry. 2015;207:501–506. doi: 10.1192/bjp.bp.113.141077.
    1. Subba P., Luitel N.P., Kohrt B.A., Jordans M.J.D. Improving detection of mental health problems in community settings in Nepal: Development and pilot testing of the community informant detection tool. Confl. Health. 2017;11:28. doi: 10.1186/s13031-017-0132-y.
    1. StataCorp L.L.C. Stata Statistical Software: Release 15. StataCorp LP; College Station, TX, USA: 2017.
    1. QSR International . Nvivo Qualitative Data Analysis Software. Version 10. QSR International Pty Ltd.; Doncaster, Australia: 2012.
    1. Jorm A.F., Reavley N.J., Ross A.M. Belief in the dangerousness of people with mental disorders: A review. Aust. N. Z. J. Psychiatry. 2012;46:1029–1045. doi: 10.1177/0004867412442406.
    1. Krendl A.C., Freeman J.B. Are mental illnesses stigmatized for the same reasons? Identifying the stigma-related beliefs underlying common mental illnesses. J. Ment. Health. 2019;28:267–275. doi: 10.1080/09638237.2017.1385734.
    1. Kermode M., Bowen K., Arole S., Pathare S., Jorm A.F. Attitudes to people with mental disorders: A mental health literacy survey in a rural area of maharashtra, India. Soc. Psychiatry Psychiatr. Epidemiol. 2009;44:1087–1096. doi: 10.1007/s00127-009-0031-7.
    1. Chiles C., Stefanovics E., Rosenheck R. Attitudes of students at a us medical school toward mental illness and its causes. Acad. Psychiatry. 2017;41:320–325. doi: 10.1007/s40596-016-0508-0.
    1. Roth D., Antony M.M., Kerr K.L., Downie F. Attitudes toward mental illness in medical students: Does personal and professional experience with mental illness make a difference? Med. Educ. 2000;34:234–236. doi: 10.1046/j.1365-2923.2000.00478.x.
    1. Zhu Y., Zhang H., Yang G., Hu X., Liu Z., Guo N., He H., Sun B., Rosenheck R. Attitudes towards mental illness among medical students in China: Impact of medical education on stigma. Asia Pac. Psychiatry. 2018;10:e12294. doi: 10.1111/appy.12294.
    1. Ay P., Save D., Fidanoglu O. Does stigma concerning mental disorders differ through medical education? A survey among medical students in istanbul. Soc. Psychiatry Psychiatr. Epidemiol. 2006;41:63–67. doi: 10.1007/s00127-005-0994-y.
    1. Bell J.S., Johns R., Chen T.F. Pharmacy students’ and graduates’ attitudes towards people with schizophrenia and severe depression. Am. J. Pharm. Educ. 2006;70:77. doi: 10.5688/aj700477.
    1. Wilkinson D. The effects of brief psychiatric training on the attitudes of general nursing students to psychiatric patients. J. Adv. Nurs. 1982;7:239–253. doi: 10.1111/j.1365-2648.1982.tb00236.x.
    1. De Vargas D. The impact of clinical experience with alcoholics on brazilian nursing students’ attitudes toward alcoholism and associated problems. J. Addict. Nurs. 2013;24:180–186. doi: 10.1097/JAN.0b013e3182a4cc43.
    1. Esen Danaci A., Balikci K., Aydin O., Cengisiz C., Uykur A.B. The effect of medical education on attitudes towards schizophrenia: A five-year follow-up study. Turk Psikiyatr. Derg. 2016;27:176–184. doi: 10.5080/u13607.
    1. Shankar P.R. Undergraduate medical education in Nepal: One size fits all? J. Educ. Eval. Health Prof. 2011;8:9. doi: 10.3352/jeehp.2011.8.9.
    1. Semrau M., van Ommeren M., Blagescu M., Griekspoor A., Howard L.M., Jordans M., Lempp H., Marini A., Pedersen J., Pilotte I., et al. The development and psychometric properties of the humanitarian emergency settings perceived needs (hesper) scale. Am. J. Public Health. 2012;102:e55–e63. doi: 10.2105/AJPH.2012.300720.

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