Anti-stigma curriculum improved attitudes, encouraged youth to seek help

A school-based program designed to eliminate the stigma tied to mental illnesses showed potential for “improving the social climate” and getting youth with high levels of mental health symptoms to seek treatment, researchers reported.

In a cluster randomized trial done in 14 Texas schools, sixth graders assigned to the “Eliminating the Stigma of Difference” (ESD) curriculum reported greater knowledge and positive attitudes, as well as reduced social distance (Cohen’s d=0.35 and 0.16, respectively) than youth in the comparator interventions and no-intervention groups across two years of follow-up, according to Bruce G. Link, PhD, of the University of California Riverside, and co-authors.

Also, kids with high levels of mental health symptoms were more likely to seek treatment during follow-up if assigned to ESD versus assignment to comparator interventions or no intervention (odds ratio 3.51, 95% CI 1.08 to 11.31), they wrote in Pediatrics.

Symptoms were based on a self-reported checklist using 21 stem questions from the National Institute of Mental Health Diagnostic Interview Schedule for Children (DISC version IV) to “identify youth with a high probability of needing professional mental health treatment,” the authors explained. “Youth endorsing two-thirds or more of the symptoms either at the beginning of the study… or at the end… were categorized as having high probability of need.”

Ultimately, 18.5% of the youth met the criteria, but Link and co-authors pointed out that there was no significant effect of the ESD intervention in youths with fewer symptoms.

The curriculum used in the study “shows promise through intervening early, addressing stigma, and advancing knowledge and attitudes that may facilitate seeking treatment for diverse youth in schools,” noted Shashank V. Joshi, MD, of Stanford University in California, and Nathaniel Beers, MD, MPA, of the Children’s National Hospital in Washington DC, in a commentary accompanying the study. “Combined with screening and improved access to school-based mental health services, this curriculum could add a critical component to addressing the mental health needs of children and youth in the United States.”

While groups such as the American Academy of Pediatrics, which recommends depression screening in adolescents ≥12 years as part of routine preventive care, and the American Academy of Child and Adolescent Psychiatry have worked to increase screening of kids and youth with mental health needs, reducing stigma across the board is still necessary, they pointed out.

Minimizing stigma can lead not only to an increased willingness to access behavioral health services but also a reduction in adverse outcomes from issues like social isolation and bullying,” they wrote.

Joshi and Beers stressed that school-based interventions can be meaningful and lasting for students, parents and staff, and teachers, and that combining the program outlined by the study authors could “add a critical component to addressing the mental health needs of children and youth in the United States.”

The study was conducted between 2011 and 2012, with follow-up at 6-month intervals through 24 months until 2015. In total, 416 youth participated in the follow-up and 75% of them participated for the full 2 years.

The authors used a fully crossed 2 x 2 x 2 factorial design to compared ESD to a no-intervention control and to two comparator interventions: contact with two young adults (one male, one female) with a history of hospitalization for bipolar disorder and exposure to anti-stigma printed materials.

“ESD is a 3-module, 3-hour curriculum delivered within 1 week, with each module involving a didactic component, group discussion, and homework exercises, Link’s group explained. The first module focuses on stigma, ways define it and end it, causes of mental illness, and barriers to treatment. The last two modules addressed mental disorders, such as attention-deficit/hyperactivity disorder, anxiety disorders, and depression. The latter modules also included “content that stimulates empathy.”

The authors also explained that “Children’s social distance… is a 6-item measure gauging the extent to which youth are unwilling to interact with someone who is identified as having a mental illness.”

They concluded that the results supported the positive impact of the ESD curriculum, in that “Youth assigned to the curriculum intervention experienced significantly increased knowledge and more positive attitudes toward mental illness and reported significantly reduced social distance from youth with mental illness.”

The finding that eligible youth were more open to seeking mental health treatment “to our knowledge, has not previously been addressed in stigma intervention research,” Link’s group wrote.

They noted that the contact intervention with the two young adults did not have an effect, which was not in keeping with conventional wisdom, but previous research has shown that contact is not as effective in adolescents versus educational interventions.

Study limitations included the use of self-reported data, lack of data on the type or adequacy of treatment, and loss to follow-up.

  1. An anti-stigma curriculum intervention for sixth graders improved knowledge and attitudes about mental illness and reduced exclusionary tendencies.

  2. The curriculum also led youth with mental health problems to seek treatment in the 2-year longitudinal follow-up study.

Shalmali Pal, Contributing Writer, BreakingMED™

The study was funded by the NIH.

Link and a co-author reported support from the National Institute of Mental Health.

Joshi and Beers reported no relationships relevant to the contents of this paper to disclose.

Cat ID: 138

Topic ID: 85,138,730,138,139,43,142,192,146,925