The Reducing Stigma Among Health Care Providers (RESHAPE) intervention may reduce stigma among primary care providers (PCPs) without significantly increasing risk of harm to people with lived experience (PWLE) of mental illness, according to new research published in JAMA Network Open.
The pilot cluster randomized clinical trial included all primary care facilities in the Chitwan district of Nepal (n=34) that did not have integrated mental health services and PCPs with prescribing privileges at primary care facilities. Assessors, PCPs, and patients were blinded to group assignment. The patients who participated had been diagnosed with depression, psychosis, or alcohol use disorder. The researchers recorded caste and ethnicity of participants because of their association with stigma, discrimination, mental illness risk factors, and differential treatment within the health system.
Half of the facilities completed World Health Organization Mental Health Gap Action Programme-Intervention Guide (mhGAP-IG) training as usual with 45 PCPs while the rest involved PWLE as co-facilitators (43 PCPs). Following dropouts, 29 facilities were included in the final analysis. When the PWLE participated, they provided testimony of their recovery (before, during and after treatment) through PhotoVoice photographic narratives, responding to questions from PCPs, and participating in social activities with them.
Social Distance Scale (SDS) for PCPs in the RESHAPE group decreased a mean 10.6 points while it decreased 2.8 points in the control group. Both groups experienced within-group improvement in mhGAP Knowledge, mhGAP Attitudes, and Enhancing Assessment of Common Therapeutic Factors (ENACT) competencies. The Implicit Association Test (IAT) did not improve within either group.
The RESHAPE group’s diagnostic accuracy in standardized role-plays decreased from 78.4% at 4 months of training to 78.1% at 16 months of training. The control group’s diagnostic accuracy increased from 57.5% to 66.7%. Actual patient diagnoses, as confirmed with Composite International Diagnostic Interview, were correct for 72.5% of patients in the RESHAPE group and 34.5% of the patients in the control group.
Diagnostic accuracy of depression had the largest absolute difference between the groups in the standardized role-plays and actual patient evaluations.
The researchers reported that there were no serious adverse events.
The study had some limitations. Limitations included that the 16 month follow-up was longer than the usual 6 month follow-up of other antistigma interventions. Another limitation was that mental health specialists conducting the trainings could not be blinded to the participation of PWLE in the trainings.
“Ultimately, the potential to collaborate with PWLE to reduce stigma and improve diagnosis is encouraging for enhancing the success of mhGAP-IG implementation and more broadly for successful integration of mental health services into primary care settings around the world,” the researchers said.
Kohrt BA, Jordans MJD, Turner EL, et al. Collaboration with people with lived experience of mental illness to reduce stigma and improve primary care services: a pilot cluster randomized clinical trial. JAMA Network Open. Published online November 3, 2021. doi:10.1001/jamanetworkopen.2021.31475