Public anti-stigma programmes might impove help-seeking

In their systematic review and meta-analysis on the association between mental health-related stigma and active help-seeking, ¹ Schnyder et al find that negative help-seeking attitudes and personal stigma are associated with less actual help-seeking. The authors connect these findings to a recommendation for anti-stigma campaigns to ‘target these personal attitudes rather than broad public opinion’. However, this recommendation cannot be extrapolated from the types of study they reviewed. Moreover, it overemphasises help-seeking as the key outcome and does not adequately consider the importance of changing wider social acceptance in broader domains related to, for example, disclosure at work or support from family and friends.

Schynder et al reviewed studies evaluating the association between stigma and actual help-seeking at the individual level. They did not assess how public-level attitudes correlated with actual help-seeking in the population, which would have required cluster-level analyses. Their individual stigma-help-seeking association is different from concluding that campaigns targeting the general public are not helpful in improving help-seeking at a population level. Because Schnyder and colleagues did not include evaluations of broad public anti-stigma campaigns on care-seeking, their recommendation against such efforts risks misleading policy makers, healthcare practitioners, researchers and advocates.

In contrast to Schnyder et al's recommendation against targeting public opinion, our work has shown that investment in population-level anti-stigma programmes can address several important challenges. Low levels of public knowledge, negative attitudes and discriminatory behaviour have significant consequences for people with mental illness. Our evaluation of the Time to Change anti-stigma campaign in England ^2,3 has demonstrated improvements in mental health-related attitudes and intended behaviour at the population level and among specific target groups, and this is supported by further reviews of anti-stigma interventions. These changes can foster a positive social context that is more supportive of people with mental illness.

Moreover, Schnyder et al's finding that self-stigma and stigma against other persons with mental illness was associated with limited help-seeking is likely influenced by community-level stigma. Individuals with mental illness internalise the broad socio-cultural environment in which they reside and may experience more discrimination when living in a high-stigma community. Individuals with mental illness and sexual minorities living in communities with higher public stigma have greater self-stigma, lower empowerment, lower chances of employment and greater risk of mortality. ^4–6

Programmes that reduce public stigma could combat social exclusion and promote social participation of people with mental illness across several important life domains. Moreover, targeted anti-stigma interventions that improve attitudes of key groups, such as employers, peers at work, law enforcement officers and healthcare practitioners, could foster support for individuals with mental illness and make a significant impact on their quality of life. Improving public attitudes, therefore, can also create a virtuous cycle.

Ultimately, the most effective approaches require multisectorial strategies incorporating persons with mental illness, the general public and key stakeholders. Extrapolating recommendations against public anti-stigma campaigns from studies only assessing associations between stigma and help-seeking at the individual level risks deterring investment from evidence-based approaches.