Collaboration With People With Lived Experience of Mental Illness to Reduce Stigma and Improve Primary Care Services

Abstract

IMPORTANCE Collaboration with people with lived experience of mental illness (PWLE), also referred to as service users, is a growing priority to reduce stigma and improve mental health care. OBJECTIVE To examine feasibility and acceptability of conducting an antistigma intervention in collaboration with PWLE during mental health training of primary care practitioners (PCPs). DESIGN, SETTING, AND PARTICIPANTSThis pilot cluster randomized clinical trial was conducted from February 7, 2016, to August 10, 2018, with assessors, PCPs, and patients blinded to group assignment. The participants were PCPs and primary care patients diagnosed with depression, psychosis, or alcohol use disorder at primary care facilities (the cluster unit of randomization) in Nepal. Statistical analysis was performed from February 2020 to February 2021. INTERVENTIONS In the control group, PCPs were trained on the World Health Organization Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG). In the Reducing Stigma Among Healthcare Providers (RESHAPE) group, the mhGAP-IG trainings for PCPs were cofacilitated by PWLE who presented recovery testimonials through photographic narratives. MAIN OUTCOMES AND MEASURES Prespecified feasibility and acceptability measures were adequacy of randomization, retention rates, intervention fidelity, data missingness, and safety. Outcome measures for PCPs included the Social Distance Scale (SDS), accuracy of diagnoses of mental illness in standardized role-plays using the Enhancing Assessment of Common Therapeutic factors tool (ENACT), and accuracy of diagnosis with actual patients. The primary end point was 16 months posttraining. RESULTS Among the overall sample of 88 PCPs, 75 (85.2%) were men and 67 (76.1%) were upper caste Hindus; the mean (SD) age was 36.2 (8.8) years. Nine of the PCPs (10.2%) were physicians, whereas the remaining 79 PCPs (89.8%) were health assistants or auxiliary health workers. Thirtyfour facilities were randomized to RESHAPE or the control group. All eligible PCPs participated: 43 in RESHAPE and 45 in the control group, with 76.7% (n = 33) and 73.3% (n = 33) retention at end line, respectively. Due to PCP dropout, 29 facilities (85.3%) were included in end line analysis. Of 15 PWLE trained as cofacilitators, 11 (73.3%) participated throughout the 3 months of PCP trainings. Among PCPs, mean SDS changes from pretraining to 16 months were −10.6 points (95% CI, −14.5 to −6.74 points) in RESHAPE and −2.79 points (−8.29 to 2.70 points) in the control group. Role-play-based diagnoses with ENACT were 78.1% (25 of 32) accurate in RESHAPE and 66.7% (22 of 33) in the control group. Patient diagnoses were 72.5% (29 of 40) accurate by PCPs in RESHAPE compared with 34.5% (10 of 29) by PCPs in the control group. There were no serious adverse events.(continued) Key Points Question Does involvement of people with lived experience of mental illness in cofacilitation of trainings for primary care practitioners reduce stigma and improve mental health services? Findings In this pilot cluster r...

Mental health stigma and discrimination in Ethiopia: evidence synthesis to inform stigma reduction interventions

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Mental health stigma at primary health care centres in Lebanon: qualitative study

“…The visual recovery narratives presented by the persons with lived experience as well as other forms of structured social interaction of persons with lived experience are incorporated into mental health trainings for PHC staff. A pilot study showed that incorporating these social contact components into PHC trainings reduced stigma, increased MHC diagnostic accuracy of HCPs, and increased willingness to endorse and deliver psychological and psychosocial treatments (i.e., not solely rely upon medication) [ 42 , 43 ]. The RESHAPE intervention is now being piloted in Tunisia, Ethiopia, India, and China.…”

Treatment Preferences for Pharmacological versus Psychological Interventions among Primary Care Providers in Nepal: Mixed Methods Analysis of a Pilot Cluster Randomized Controlled Trial

“…A full description of the RESHAPE training curriculum has been published previously [ 24 ]. Table 1 presents the contents of the 10-day training for prescribers and 5-day training for non-prescribers, as well as the elements that constitute RESHAPE [ 27 ].…”

“…This minimized the risk of contamination across arms. Full details of the cluster design are in the study protocol [ 22 ] and details of cluster retention are available in the pilot primary outcome publication [ 27 ].…”

“…We hypothesized that the RESHAPE version of mhGAP-IG would contribute to greater endorsement of psychological treatment because of the empathy and humanistic perspective fostered through social contact with PWLE [ 23 , 24 , 25 , 26 ]. The pilot findings suggest that RESHAPE improves both attitudes towards patients with mental illness and accuracy of mental illness diagnoses [ 27 ]. In the current analysis, we conduct a secondary exploration of the trial data and use a mixed methods approach to evaluate quantitative differences in treatment attitudes of PCPs across arms.…”