Mental Illness Stigma and Ethnocultural Beliefs Values and Norms an Integrative Review

Abstract

Groundwork

Depressive disorders are a serious public health concern. Left untreated, further clinical distress and damage in important life domains may arise. Yet, the treatment gap remains big. Prior research has shown that individuals with depressive disorders prefer seeking help from informal sources such as family and friends alee of formal sources. Notwithstanding, this preference has its disadvantages such as experiencing actual, perceived and internalized stigmatizing responses from them which may filibuster or deter help-seeking. This paper aimed to determine the role of perceived stigma among family and friends in an individual's help-seeking behavior.

Methods

Data were collected using semi-structured interviews with patients with depressive disorders from a 3rd psychiatric hospital in Singapore to capture individuals' self-reported experience with depression and stigmatization among family and friends. Interviews were audio recorded and transcribed verbatim. Data of 33 young adults (mean historic period = 26 years, SD =four.6; 18 female, 15 male) were analyzed using thematic assay.

Results

In all, four broad themes were developed: (1) absence of support, (2) provision of unhelpful support, (iii) preference for non-disclosure, and (4) opposition towards formal aid-seeking. Lack of sensation of low and perpetuation of stigma manifests as barriers towards help-seeking in the form of absence of support and provision of unhelpful support which afterward leads to a preference for non-disclosure, every bit well as opposition by family unit and friends towards formal help-seeking.

Conclusions

Data from this study tin can contribute to the development of public health programs aimed at improving sensation and support from family and friends and facilitating earlier aid-seeking amid young people with depressive disorders.

Peer Review reports

Introduction

Depressive disorders remain a serious public wellness concern. Based on a report past the World Health Organization (WHO) in 2017, an estimated four.iv.% of the world's population have depression, of which approximately 27% (86 million) reside in Southeast Asia [one]. Symptoms of Major Depressive Disorder (MDD) can outcome in significant clinical distress and impairment in important life domains such as employment and interpersonal relationships [2]. Left untreated, further problematic consequences may ascend. A systematic review and meta-analysis conducted by Ghio et al. [three] summarized that a longer duration of untreated affliction is a strong predictor of poor response to anti-depressant treatment, lower charge per unit of remission, college run a risk of chronicity, too every bit higher number of recurrences. This renders timely and advisable help-seeking of paramount importance in an private's journey to recovery. Yet, treatment gaps remain large, with common barriers to help-seeking being cost of treatment, stigmatization, and lack of perceived demand for handling [4,5,6,7].

Rickwood et al. [8] had divers help-seeking for mental health bug as "an adaptive coping procedure that is the endeavour to obtain external help to deal with mental health concerns". This includes seeking assistance from both formal (e.g., wellness professionals or services) and informal (due east.m., friends and family unit) sources. Prior research has shown that individuals with depression prefer seeking help from breezy sources such equally from family and friends ahead of support from formal sources [nine,10,eleven]. This preferred source of support is unsurprising every bit there are some perceived advantages from consulting family and friends such as receiving emotional, informational, and instrumental support [12, 13]. Moreover, perceived positive support from breezy sources has been associated with improved recovery among individuals with a depressive disorder [14]. Nevertheless, there are some concerns that seeking help from informal sources can lead to unhelpful or harmful consequences, such as experiencing actual, perceived and internalized stigmatizing responses [12]. Equally interaction with family and friends are likely to exist more frequent, they are at a crucial position to provide emotional and informational back up which facilitates formal help-seeking, which is, help from health professionals [xiii]. In contrast, stigmatizing responses from family and friends may delay or deter individuals from seeking help from both informal and formal sources.

Stigma is a distinctive feature associated with mental disease [15]. According to Corrigan et al. [16], stigma consists of three related concepts: stereotypes, prejudice, and bigotry. Stereotypes, which tend to be culturally adamant, are oversimplified ideas including preconceptions virtually traits or abilities of people belonging to a specific group. Information technology emphasizes the differences between people from this group and another grouping; consequently, drawing people to focus on information that aligns with the stereotypes and ignoring those which exercise non. Prejudice on the other hand is a negative attitude based on stereotypes towards people belonging to a specific grouping. Stereotypes and prejudice can atomic number 82 to bigotry, which is the unjust behavior towards people belonging to a specific group. In the context of mental affliction, stigma of mental illness can create social distance or rejection in the grade of subtract in opportunity for employment (discrimination), resulting from negative labels (stereotype) placed on people with mental disease (e.one thousand., unstable, dangerous, and unpredictable), and fear of them (prejudice). Consequently, such stigma can discourage individuals from seeking treatment due to the anticipation of being labelled with a mental illness and existence discriminated confronting [17].

Stigma towards mental illness is pervasive and cultural contexts may shape its form [18]. In Asia, mental illness is often associated with stigma, shame and "loss of confront" (losing the respect of others) for the individual and their family members [19, xx], which could be partly due to the Asian values of collectivism [21]. In Singapore, research has identified similar associations such as perceiving that people with mental disease are unpredictable and that the illness is a sign of personal weakness [22]. Furthermore, results from a study conducted among 940 youths in Singapore constitute that 46.2% said they would be embarrassed if they were diagnosed with a mental illness, 22.7% said they practise not want others to know if they had a mentally ill relative, and 35.1% said their friends would see them as weak if they had a mental illness [23]. These collectively propose that mental affliction is seen every bit a mark of shame among youths in Singapore and it is something that peers would stigmatize.

Singapore is a multi-ethnic country in Southeast Asia with a population of approximately 5.7 million in 2019, comprising mainly Chinese (74.3%), Malays (13.5%), Indians (ix%), and those belonging to other ethnic groups (three.2%) [24]. Based on a national survey of mental wellness disorders in 2016, the lifetime prevalence of MDD was 6.three% among the general population aged between xviii and 65 years and nine.2% for those anile between xviii and 34 years [25]. Despite low being a prevalent condition and identified by youth in Singapore as one of the top bug they faced [26], a large treatment gap remains credible [6, 25, 27]. Furthermore, the Mind Matters study – a population-based cantankerous-exclusive study conducted among Singapore residents – establish that approximately half of the participants endorsed "talking to family unit or friends" as the about recommended source of help for depressive disorders [10].

Connexion and group cohesion are important values in a collectivist culture [28] as are deference to authority figures and maintenance of interpersonal harmony with the family [29]; therefore, it is probable that people belonging to a collectivist culture would involve their family members in their decision making and adopt choices made by trusted others. This is echoed in prior research findings where there was a preference for family-centered decision making in mental health care among Eastward Asians [30].

Prior inquiry has shown that family members of those with mental illness experience associated stigma and its negative consequences. In Yin et al.'southward [31] qualitative systematic review of experience of stigma among family members with severe mental illness, the authors highlighted that family members experienced social exclusion, isolation and received nasty comments that devalue and ridicule them due to their mentally sick family members. Importantly, the authors noted that some family unit members tried to cope with the stigma by concealing mental illness from others to avoid discrimination, or by reducing contact with others to avoid being confronted with stigmatizing reactions. Reaction and coping styles from families can in turn have implications on the mode individuals with mental illness cope with their disease.

Aside from the family's response, exposure to stigmatizing responses from peers towards mental disease too can influence the way individuals with mental illness cope with their illness. For example, some adolescents reported censoring their need for psychiatric medication due to the perception that taking medications would make them feel unlike from their peers, or to avoid being outcasted or humiliated for taking them. This usually stemmed from being exposed to hearing people advise that psychiatric medications are for people who are "crazy" [32].

As it was commonly constitute that breezy sources are the preferred source of assistance for depressive disorders, and commonly recommended among Singapore residents in an before written report that examined mental health literacy [10], it is worthwhile to explore how stigma towards low among breezy sources in this cultural setting influence individuals' aid-seeking beliefs. Such data would exist useful for interventions or educational programs aimed at improving recognition and back up by informal networks of individuals with depression.

Data from this paper is based on secondary analysis of a study past Teh et al. [33] who examined Singaporean young adults' narratives of their experiences with depression, with a focus on their perceptions of the illness. The authors found that young adults typically experienced depression as a 'reduced state of being' and faced conflicts betwixt the self and their social environment. The paper also brought forth important sociocultural nuances in the agreement of and feel with depression, such as their struggles to run across unrealistic societal expectations and construct meaningful goals that are aligned with familial and societal expectations as key contributors to depression. The present study thus hoped to aggrandize on their inquiry past delving deeper into the implications of sociocultural factors in help-seeking behaviors and experiences. Using qualitative methods, the aim of this report was to explore the role of stigma from family and friends in help-seeking behaviors among young people with depression. Our research questions include: (1) Are individuals with low stigmatised past their family and friends? and (two) How do these experiences delay or deter help-seeking?

Methods

Study Blueprint

The present study applied a qualitative methodology. Following an interpretative approach [34], semi-structured interviews were used to obtain narratives of young people's experiences with stigma from their family and friends and its role in help-seeking. The study was carried out in accordance with the latest version of the Annunciation of Helsinki and ideals blessing was obtained from the National Healthcare Grouping Domain Specific Review Lath (NHG-DSRB) and the Institute of Mental Health, Institutional Enquiry Review Committee (IRRC). All participants provided written informed consent prior to their participation. Reporting of this report was guided past the consolidated criteria for reporting qualitative studies (COREQ) [35] (see Additional file ane: Appendix A).

Participants and recruitment procedure

Participants were recruited from the Institute of Mental Wellness (IMH), a tertiary psychiatric hospital in Singapore between February 2018 and January 2019. Inclusion criteria for the study were: being a Singapore citizen or permanent resident, aged between 18 and 35 years, receiving handling at IMH outpatient clinics, having a diagnosis of depressive disorder, and willing and able to requite written consent. Participants were excluded if they had a diagnosis of substance-induced depressive disorder, depression with psychotic symptoms, bipolar disorder, depressive disorder due to a full general medical condition, or were women with post-natal depression. Participants were recruited via convenience sampling and purposive sampling to obtain adequate representation by ethnic groups. No relationship was established betwixt participants and study squad members prior to study beginning. Participants were either referred by their clinicians during their outpatient visit or inpatient stay; in the latter example, they were recruited during outpatient follow-upward or approached at the outpatient clinic by a written report team fellow member with information flyers detailing the aim, procedures, criteria and potential risks and benefits of the study. Of the 52 individuals approached, 14 refused to participate. Some did not mention a reason for refusal while others said they were disinterested, busy, or uncomfortable with beingness interviewed. Four participants were withdrawn as they did non fulfil the eligibility criteria. 34 participants (xix females, fifteen males) completed the interviews. One transcript was excluded from analysis as it differed essentially from the rest of the transcripts where discussions were primarily associated with another medical status.

Data collection

Face-to-face semi structured interviews were conducted with participants by study squad members [ES, WLT, KR, FD, LC, and SS] who are researchers with degrees in psychology (i.e., BA/BSc in Psychology, Masters in Clinical Psychology), trained in qualitative inquiry and had prior experience in conducting qualitative interviews. Study team members consisted of both males and females. As the communication styles of individuals in Asian cultures differ substantially from Western cultures, i-to-one interviews were preferred over focus grouping discussions [36]. A semi-structured interview format was besides chosen to guide the management of the interview yet remaining flexible to allow follow-up of noteworthy areas of accounts which may surface during the interview. Semi-structured interview questions from the larger study past Teh et al. [33] included: What practice yous personally believe led you lot to being depressed? How has low affected you lot? How take you coped with low? What does your family or culture think of depression? Does the way your family or culture think of low affect the way you lot retrieve of low? Follow-up prompts (Tin yous tell me more well-nigh it? Could you give me an case of this?) were also used.

All interviews were conducted within the IMH facility except for i interview which was conducted exterior IMH for the convenience of the participant. Simply the participants and researchers were nowadays during the interviews. To ensure sensitivity to participants' ethnocultural perspectives, most participants were matched with interviewers of similar ethnicity. Interviews ceased in one case data saturation was reached, where no new information was observed and collected. Interviews were audio-recorded, transcribed verbatim and checked for accurateness by study team members. Each interview lasted between approximately 33 and 120 min (boilerplate 63 min).

Information analysis

Transcripts were pseudonymized via consignment of an alphabet (C, M, I) based on ethnicity followed past a number in sequence of recruitment for that ethnic group (e.1000., C01, M01, I01). Transcripts were uploaded onto Nvivo software, a qualitative data analysis software, for data management and analysis [37].

Analysis was undertaken by five written report squad members [ES, WLT, KR, FD, and LC]. In analyzing the data, a combination of inductive and deductive approaches was used where data drove and assay happened simultaneously and iteratively [38, 39]. For the anterior approach, the study team members independently read each transcript and collaboratively extracted and coded meaningful data units using the open coding method [twoscore]. Initial codes were generated into higher order concepts and themes based on their mutual properties and a codebook was developed. The report team discussed and reviewed fundamental emergent themes extensively while constantly comparing new information with previously collected data as role of the deductive approach where pre-existing codes were used equally a guide and template for the clustering of newly collected data. The codebook was regularly refined until data saturation was accomplished where no additional data were found to develop new themes. Using Nvivo, five coders [ES, WLT, KR, FD, and LC] coded the same transcript and their coding was compared using the coding comparison function which yielded an average kappa score of 0.73, indicating loftier inter-rater agreement among the five coders.

The adjacent step was performed by 2 study squad members [ES and WLT] which consisted of examining one of the primal themes identified in the information. This theme related to participants' experiences with their family and friends' reactions towards their depression. ES and WLT further classified information from this theme into singled-out but interrelated themes using the thematic analysis approach as informed by Braun et al. [41] to identify, clarify, and study patterns within the data set. This approach was chosen as it is particularly suited to interpreting the conceptualization of a phenomenon by a specific group [42]. Using NVivo as a information management tool, ES and WLT generated initial codes and sub-codes in a systematic manner (run across Additional file two: Appendix B), which were so grouped into potential themes. Transcripts were consistently checked to ensure that quotes were congruent with the themes.

Results

Data for the nowadays study were gathered from interviews with 33 participants (18 female, 15 male) betwixt the ages of 20 and 35 years (mean = 26; SD = 4.6). All participants were outpatients who had a diagnosis of depressive disorder co-ordinate to the Diagnostic and Statistical Manual, 4th Edition (DSM-4); 2 of whom had comorbid low and anxiety. Duration of depressive disorders varied from four months to 16 years, with a median of two years. The participants came from a multifariousness of educational and employment backgrounds: 26 participants graduated from vocational school, junior college, or higher, and seven with secondary school education or lower; vii were students, 18 had full-time or role-time jobs, and 5 participants were unemployed at the time of the interview. The overview of participants' characteristics can be seen in Table ane.

Tabular array 1 Participant characteristics, diagnosis, and other sociodemographic information (due north = 33)

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In all, iv interrelated broad themes emerged from the information: (one) absence of back up, (2) provision of unhelpful support, (3) preference for non-disclosure by individuals with depression, and (four) opposition towards formal assistance-seeking, each encapsulating the manifestations of stigma by family unit and friends towards depression as barriers to help-seeking for mental health issues. The overview of themes and sub-themes can be seen in Table 2. To ensure that standard usage of English language is maintained, minimally corrected verbatim of quotes are shown.

Table 2 Overview of major themes and sub-themes

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Absenteeism of support

A major finding from this enquiry is the absence of support by family and friends. This absence is likely driven by their misconceptions of the illness, such equally assertive that depression is non a serious or real medical condition, or shame associated with the illness.

Ignoring cries for help

A few participants had mentioned the inability of family unit and friends to recognize the severity of their depressive symptoms and had instead ignored or trivialized their experiences.

"they're non doing anything to assist considering to them it's like, ah depression, my friend besides got depression, my male parent besides got depression, nothing similar… to them it's nada serious" (M01/26/M/Malay).

On the other mitt, some were more explicit in sharing their family's denial of the illness as the cause of their inaction towards cries for assistance.

"My blood brother told my mom that he's not okay only to my parents it'due south just like your life is not and then…then messed upwardly for you to be depressed. Like she said similar Princess Diana she controls the whole country, she has the right to be depressed. You are just a normal boy, yous cannot take depression. Like they tin can't accept their children having low. But the thing is – aye, I sympathise – merely the thing is nosotros voiced out for assist, nosotros are crying for assist already so you need to do something about information technology and non simply because you don't want other people to know that my children got low." (C07/24/F/Chinese).

"My father is like kind of clueless about it. He's like in denial? "Oh, she'south alright, she'south alright." Like I'grand sitting down there, crying "oh, you're alright, you're alright" like in denial that kind of thing." (M10/29/F/Malay).

Brushing off symptoms with insensitive remarks

Some participants expressed beingness brushed off with dismissive remarks that minimized and even normalized their experiences when they sought help from family unit and friends.

"Even if I told them, they wouldn't have it seriously. Like afterward I tried to kill myself, I went to them and and so they simply brushed it aside, only equally a reaction to stress." (L05/21/Chiliad/Indian).

Akin to the example in a higher place, some of the dismissive remarks experienced by participants suggests the lack of belief in depression as a real and chronic medical condition amongst family unit and friends. In fact, many of the participants' narrations bespeak that depression was instead seen every bit simply an experience of regular emotions:

"they don't see it every bit an disease; they see it as emotions you see. So that's why they were like oh you feeling like this (it's) you giving upwards, information technology's simply you…" (M03/27/M/Malay).

Or an individual's way of inflating their present situation for their own personal gains such as to avoid responsibilities:

"…information technology's just frowned upon on like people who attempt to chao keng (malinger), like they go and simulated MC (medical certificate) for something or what. So there's e'er this belief that people with mental illnesses are only chao keng-ing (malingering) ah, they are just faking information technology"(C11/22/M/Chinese).

Provision of unhelpful back up

Another major finding includes the provision of unhelpful support by family and friends – a manifestation of ignorance and negative attitudes towards depression – and the resultant feelings of the participants.

Inappropriate comparisons with other experiences

It was noticeable in their recounts that participants yearned for empathy and a 'listening ear' from family and friends. However, family and friends oftentimes tried to chronicle participants' experiences with their own or experiences of others. Although these responses were in some instances well-intended, participants felt that their situations were dissimilar and were unable to gain insights from those comparisons, and fifty-fifty found them unhelpful.

"I will tell them I'grand having trouble sleeping or I'm having trouble concentrating and they'll be similar "yes, yeah, me too…I'one thousand too very stressed about exams." But and then after exams they are all like 'La Di Da' happy merely I'k still feeling the same,"(L09/26/F/Indian).

On a related note, another participant described her friend's attempt to make sense of her situation simply in doing then, invalidated her experience and emotions by comparison it with another situation which was perceived to exist worse:

"I kind of notice information technology abrasive when people like tell me, similar other people have it worse. Showed me pictures of hungry children, "See they having it worse why you feeling like that?" You know that kind of thing? Every time I feel sad, people will as well, "You run into, got children hungry. You are hither got food, got a roof over your head. Why y'all sad?" You know? You know all this sort of thing? And so it'south like, a comparison." (M10/29/F/Malay).

Comparisons with situations that were deemed to be worse were also seen in other narrations, usually with previous generations' experiences of having to deal with seemingly tougher situations even so not experiencing depression; as though alluding to the lack of strength of one'south character every bit an explanation for depression.

"In the past they (parents) did not have money, or roof over their heads, but they are able to survive, and how is it that youngsters nowadays with food and shelter over the caput, got mental problems?" (C10/22/F/Chinese).

Providing unsolicited or unhelpful advice

Echoed amongst participants was an disability by family and friends to react to their affliction in a manner which participants plant useful. Instead, they were given unsolicited advice over existence listened to and empathized with, which was the response nearly participants had sought for.

"I understand from another point where you know you requite a lot of advices and stuff but I feel like nosotros don't really need them. Nosotros don't really demand advice we just demand yous to mind and understand how we feel…" (C10/24/F/Chinese).

Among the unsolicited or unhelpful remarks which showed an disability to fully understand the nature and etiology of depression, were participants being asked to negate their depressive symptoms (e.1000., "don't be stressed" (C05/34/F/Chinese), "merely don't feel sad" (L08/22/F/Indian)), to non dwell on them (e.g., "information technology's cypher if yous don't call up well-nigh it" (M12/26/F/Malay)) or to "snap out of information technology" (C10/22/F/Chinese). Participants also found it particularly unhelpful when they were encouraged to simply remember positively (due east.g., "be more positive, exist stronger" (C11/22/M/Chinese), "there'due south a light, merely be patient" (M09/35/F/Malay)).

It was also common among family and friends of Malay participants to advise them to pray and strengthen their faith to overcome depressive symptoms. These communication tend to stem from the belief that low was due to weak faith, supernatural causes, or that divine intervention tin convalesce depressive symptoms. Although well-intentioned, participants felt that they needed more than than just prayers to assistance their condition.

"And then therefore she (mother) believes like the more than you pray, the more you're praying the sins away and like you lot brand improve decision and stuff similar that." (M07/25/F/Malay).

"The first question I usually get, "Why? What makes you depressed?" or like "Ingat Allah (Call back God)", basically they always link it back to religion or there'due south something wrong with you lot like, like go for, like they think got Satan or something like that if that makes sense."(M06/22/F/Malay).

Attributing depression to one'south grapheme flaws

A few participants spoke of attempts from family unit and friends to rationalize their experiences of depressive symptoms past placing blame on their character. Participants were typically assumed to exist "lazy", "uninspired", or "weak". In particular, a participant was scolded for showing depressive symptoms:

"They (family) were not like accepting of uh seeing me at my worst and then their way of dealing with it was to like scold me, maybe to them they recollect they tin can, they tin can… like wake me out of it with scolding but certain if it's just… if information technology's a lazy person peradventure you can. I couldn't assistance simply think that they only keep choosing to recollect that actually I am lazy, I'thou being lazy…" (C08/31/F/Chinese).

Preference for non-disclosure

Family and friends' stigmatizing behavior and unsupportive or unhelpful responses towards their depression in full general or remarks on how individuals tin can overcome their status had discouraged some participants from seeking assist. In particular, some found these reactions to lack empathy, agreement, or to be insensitive, which resulted in the experience of negative emotions such as feeling disheartened, frustrated, exhausted, and annoyed.

"And I'll feel very tired to explain again. I'll just mm… like that. And so like cause sometimes giving the same response over, and once again, it tires you out." (C12/F/22/Chinese).

these reactions had also resulted in some individuals preferring to mask their affliction, not talk near it, and rely on themselves instead, which led to the worsening of depressive symptoms for some.

"…they're only telling me "no you lot but lazy, you but distressing, you just erm you lot're not finding… you're not inspired you know, bla bla bla bla" and and so the more than I feel defeated, the more depressed I feel, so the more than I hide information technology."(M09/35/F/Malay).

"The reaction to mental illness is there'southward always a problem with the person, that's why they caught information technology. So… I'thousand not as open near this. I don't dare to tell people because I'm afraid of them knowing… I feel like I explain to them they don't empathize. They really don't understand then what's the point? So you lot'll feel very lone in this whole illness" (C05/34/F/Chinese).

In addition, two participants specifically mentioned the part of stigma within their cultures in not dealing with their disease

"Culture has influenced me in a mode where I simply don't want to deal with it. Like knowing that it's a negative matter, the more I'thousand similar "Nah, I don't want to bargain with this right now."(L08/22/F/Indian).

Or beingness more reluctant to open upwardly to someone from the same ethnic group. This was due to having encountered culturally specific stigmatizing responses; therefore, finding it easier to confide in someone from a dissimilar ethnic group.

"I'm less reluctant to open… Like information technology'southward easier to open up up to a Chinese friend than to open up up to a Malay, like no criminal offence only like people who are really skilful in agama (religion) because and so they volition like, ya ya your faith is not potent plenty, those kind."(M06/22/F/Malay).

Opposition towards formal help-seeking

Some participants were met with opposition and reluctance from their family to seek help from formal sources (i.eastward., wellness professionals) due to varying reasons including denial of affliction, beingness ashamed of the illness, and distrust towards psychiatric practice.

Disability to accept the affliction

Based on participants' narrations, some families were unconvinced of the existence of their illness or were struggling to accept the disease. This denial was by and large due to perceiving low as an embarrassment; thus, the hesitance to seek treatment or preferring to continue the illness hidden.

"When they institute out when I was admitted here (third psychiatric hospital), they were angry about information technology and later on that they want to keep it…sort of kept it cloak-and-dagger. They don't want people to know." (L08/22/F/Indian).

"It'due south simply that my family has ever been very hesitant. Non because the therapists are bad but considering they are just having problem dealing with it. Or coming to terms with what they are having to do. It'southward a lot of shame, it's a lot of deprival."(M09/35/F/Malay).

By extension, the shame of being tagged as having a mental affliction creates discomfort to seeking professional treatment and having a mental affliction record in the registry. therefore,  As such, some families had wanted the illness to exist managed by the individual or inside the family.

"they were likewise very reluctant to ship me to a hospital to get handling. Like they wanted me to manage it on my own with the individual psychiatrist or manage it on… within the family but… so I guess that's i of the reasons why I likewise didn't want to go to A&E because it'due south… my parents were also kind of hesitant to practice that, maybe considering they're besides afraid of the mental illness record" (C11/22/G/Chinese).

Distrust of psychiatric practice

Evidence of distrust towards healthcare professionals and western medicine by family and friends was present in some of the participants' narrations. These include questioning the authenticity and legitimacy of clinical do by therapists and doctors and believing that monetary gains were the motivation behind their practice. In fact, some brash against taking western medicine due to fears of worsening the symptoms while some believed in alternative treatments such as spiritual healing to treat the condition instead.

"My father even says things like ultimately at the terminate of the day, the doctor demand patients to earn money, so like, yah…so you cannot believe all the things that the doctor say considering they just want to keep you lot as their patient to earn money." (C08/31/F/Chinese).

" …once again they don't, they (family), they're really old school, they don't agree with medication, they think I'thousand wasting my coin on a therapist, they think that I merely need to pray and and then everything will exist ok." (M05/28/Yard/Malay).

In light of the written report findings, we suggest a conceptual model (Fig. ane.) delineating the relationship between stigma amongst family and friends, and barriers towards help-seeking among individuals with depression. In short, lack of awareness of depression by family and friends results in a reliance on sociocultural norms to understand depression, which contributes to the perpetuation of stigmatizing attitudes towards low. This in turn manifests every bit barriers towards help-seeking in the grade of absence of back up and provision of unhelpful support which subsequently leads to a preference for non-disclosure, also as opposition by family unit and friends towards formal help-seeking. This model can be utilized as a guide for future research and the development of interventions or educational programs targeted at family unit and friends of individuals with depression.

Fig. ane

Conceptual model underlying human relationship between stigma and barriers to assistance seeking for mental health problems

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Discussion

Prior qualitative studies accept been conducted in other countries and cultural settings on mental illness stigma among family and friends, such as the experience of associated stigma, their role in stigma development, perpetuation of stigma, and how individuals with mental affliction react to the stigma (internalized stigma) [31, 32, 43]. This qualitative report conducted in Singapore examining the complex function of perceived mental illness stigma of family and friends on aid-seeking adds further to the current literature in this expanse of research.

Findings from this written report indicate the presence of considerable stigma from family and friends. While it seems unsurprising given similar findings on public stigma amidst community samples worldwide and in Singapore, it is worth noting that prior inquiry has often found levels of stigma towards mental illness to be lower among those who have had contact with individuals with mental illness [22, 44]. Nonetheless, results from this report reflect that stigmatization past an individual's informal network i.e., family and friends, is notwithstanding a problem and can touch on the individuals' assistance-seeking behaviors.

As evidenced by the narratives of participants in this report, family and friends typically respond to the illness based on their perceptions of the illness and understanding of its etiology, which tends to exist based on poor depression literacy and cultural stigma of the affliction (eastward.yard., depression is simply a normal emotion, depression is due to lack of religion, people with depression are lazy or weak, depression is a mark of shame, or individuals are malingering depression). This creates a problem when it delays help-seeking by afflicted individuals. For case, there were significant mentions of low beingness attributed to supernatural elements among the Malay participants in our study, whereby a lack of organized religion makes a person susceptible to such disturbances; a conventionalities that is perhaps strengthened past the practice of traditional healers who incorporate religious and cultural aspects in their treatments and whose approaches are well accepted within the community and are perceived to take encouraging treatment outcomes [45]. This observation is corroborated by a contempo local qualitative study by Tan et al., [20] and a report conducted in Malaysia by Khan et al. [46]. Where supernatural elements were attributed to depression in this study, family unit and friends often advised participants to strengthen their faith in the religion and seek help from God to alleviate these symptoms. Notwithstanding, having such beliefs tin be problematic when the recipient of the advice disagrees with the opinion and rejects the advice. Furthermore, advice which is perceived to lack empathy tin crusade them to shut themselves off from others and rely on themselves instead equally seen in multiple narrations in this study, which is an important bulwark to help-seeking among young people [47].

While not unique to our present written report [48], a rather concerning observation which this report revealed is the opposition by families and friends towards formal assist-seeking. Instead, it was clear in our study that some families were keen towards suppressing the illness or keeping it hidden rather than to seek aid for it. Cultural factors concerning values and norms are often cited to explicate the underuse of mental health services [49, 50]. In our study, the discomfort to acknowledge depression and opposition towards use of mental health services were mainly due to shame associated with having the illness as seen with prior studies [19, 51] and not wanting others to know, which was peradventure spurred by a bourgeois culture [21]. In addition, the prominence of shame effectually mental illness here could have been due to greater emphasis on moral attribution of mental disease in Asian societies [52] and the perception that mental illnesses reflect flaws of the family [53]. Importantly, the exercise of fugitive acknowledgement or give-and-take of subjects that are uncomfortable and shameful to talk most such every bit mental illness – 'No, this is a family affair, don't talk well-nigh it. Shameful you know' – then develops into a taboo subject, impeding appropriate help-seeking behavior.

Distrust of psychiatric practice is not an uncommon finding. Prior studies take shown that in that location are people including patients, as well as lay public, who incertitude professional treatment including mental health professionals and the effectiveness of antidepressants [54,55,56]. Instead, preference to handle problems past themselves and unwillingness to self-disembalm bug were oftentimes observed among those with mental health problems [57, 58]. In our written report, participants reported that their family and friends were distrusting of professional help, specifically in terms of not believing in the legitimacy of exercise of mental health professionals, and the lack of trust in western medicine to treat the atmospheric condition. This distrust can be traced back to the attributions of depression described before such as lack of organized religion and weak character thereby believing that these personal deficits should be counteracted with just praying or strengthening one's character, which may be unhelpful. This distrust towards psychiatric practice past families and friends tin can be specially tricky in instances where individuals believe that the family should decide where further assistance should exist sought from [59, 60]. In addition, given the Asian context and their relatively young age, immature people might expect to their family to finalize the decisions for them.

Support from family and friends are important enablers to seeking assist from a formal source. In their review of perceived advantages and disadvantages to seeking aid from breezy sources, Griffiths et al. [12] identified that participants received advisory support from family unit and friends in the grade of gentle encouragement and guidance towards formal sources of help. Participants also reported that family and friends assisted in evaluating their electric current condition and recognizing their depressive symptoms and need for professional aid. Thus, informal sources of help should have acceptable skills, cognition, and low literacy to recognize mental health issues and its need for professional help, equally well as to recommend professional aid when necessary. Seeking timely and appropriate professional assistance is essential for early detection, treatment, also as recovery from mental disease [61, 62].

Implications

This written report revealed that stigmatization by family members is a problem and should be addressed. Based on the model (Fig. 1.) derived from the present study, interventions could be implemented to address the respective components of the model. To address lack of awareness of depression and stigmatizing sociocultural perception of the illness among family members and friends of individuals with low, educational and anti-stigma programs that are culturally sensitive could be implemented at the population level. A population-level intervention seems appropriate given the prevalence of any mental disorders of nigh 1 in 7 individuals [25], where the likelihood of being a relative or/and friend of individuals with mental affliction is relatively loftier. Furthermore, at that place is evidence that mental health educational programs for the public tin can improve mental health literacy and reduce stigma towards mental illness [63]. Key components of the programme could include addressing causes of depression and perception of psychiatric practise in a culture-appropriate fashion. In addition, to address the component on absence of appropriate support and provision of unhelpful support, the plan could inform the public of means to provide emotional and instrumental support in a sensitive and respectful fashion, highlighting the impact of their response towards the illness, and identifying various forms of support in which individuals with depression discover helpful and unhelpful. Emphasis on the importance of early diagnosis and handling leading to amend outcomes should likewise be made.

Educational programs on providing helpful support targeting young people could also be reinforced in schools given that friends of individuals with mental disease are oftentimes sought for back up yet are unable to provide appropriate help. This is specially needed because Pang et al.'south [23] observation that a meaning proportion of youths in Singapore report having footling education about mental health which could explicate the stigma endorsed past the sample in their report. Furthermore, at that place are evidence of the improvement in depression noesis and reduction in stigma equally seen in an anti-stigma intervention carried out amid academy students in Singapore [20].

Limitations

Our findings should be considered in light of several limitations. Information on stigma amid family and friends are limited to self-reports by young people, and therefore may not accurately capture the intricacy of the stigma and its office in assistance-seeking. In addition, this study did not investigate whether experienced stigma differed for individuals with different sociodemographic backgrounds. It is possible that males and females differed substantially in their patterns of response. Furthermore, we did not investigate the nature of the human relationship between individuals with low and their family and friends or their functioning and dynamics. Information technology is besides possible that differences in nature of relationship or functioning may explain varying responses and attitudes towards these individuals besides. Future inquiry could also target caregivers and friends of individuals with depression and explore their experiences of supporting or caring for individuals with depression and their information needs.

Conclusions

In essence, our research highlights the considerable stigma that exists amongst families and friends of individuals with depression. As contact with family unit and friends are likely to be more frequent, it places family and friends in an optimal position to facilitate earlier aid seeking and improve longer term outcomes and decrease recurrences of depression. However, significant stigma towards depression which withal exists among families and friends cultivates inadequate and inappropriate forms of back up and delays formal help-seeking. This renders improving mental health literacy and reducing stigma among families and friends a key issue to be addressed.

Availability of data and materials

Data for this report are available upon reasonable request. The information request can be sent to The Institutional Research Review Commission, Constitute of Mental Health, Singapore; E-mail address: imhresearch@imh.com.sg.

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Acknowledgements

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Funding

This enquiry is supported past the Singapore Ministry of Health's National Medical Research Council under the Centre Grant Plan (Grant No.: NMRC/CG/M002/2017_IMH).

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1. Inquiry Division, Plant of Mental Health, Buangkok Light-green Medical Park, x Buangkok View, 539747, Singapore, Singapore

   Ellaisha Samari, Wen Lin Teh, Kumarasan Roystonn, Fiona Devi, Laxman Cetty, Shazana Shahwan & Mythily Subramaniam

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ES is the first writer and drafted the manuscript for submission. ES and TWL were responsible for data collection, the report's topic and telescopic, enquiry of evidence as well as analysis and estimation of data. KR, FD, LC and SS were involved in data collection, coding of data, and provided intellectual input into the article. MS supervised the written report and provided intellectual input into the commodity. All authors read and canonical the final manuscript.

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Correspondence to Ellaisha Samari.

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Samari, Eastward., Teh, Due west.Fifty., Roystonn, Thou. et al. Perceived mental affliction stigma amongst family and friends of immature people with depression and its role in help-seeking: a qualitative inquiry. BMC Psychiatry 22, 107 (2022). https://doi.org/ten.1186/s12888-022-03754-0

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• Received: 25 July 2021

• Accepted: 31 Jan 2022

• Published: 11 February 2022

• DOI : https://doi.org/10.1186/s12888-022-03754-0

Keywords

• Depressive disorders
• Help-seeking
• Stigma
• Immature people
• Qualitative

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