Analysis of interventions to reduce stigma related to mental disorder: a critical systematic review

Análise de intervenções para reduzir o estigma relacionado ao transtorno mental: uma revisão sistemática crítica

Análisis de las intervenciones para reducir el estigma relacionado con los trastornos mentales: una revisión sistemática crítica

1. Flávio Veloso Ribeiro

Affiliation of authors:

1 [Mestrando, Universidade Federal do Tocantins, UFT, Palmas, TO, Brasil. Diretor-secretário da Associação Tocantinense de Psiquiatria (ATOP), Palmas, TO, Brasil]

2 [Mestrando, Universidade Federal do Tocantins, UFT, Palmas, TO, Brasil. Diretor tesoureiro da Associação Tocantinense de Psiquiatria (ATOP), Palmas, TO, Brasil. Professor, Faculdade de Ciências Médicas, Afya, Palmas, TO, Brasil]

3 [Professor, Universidade Federal do Tocantins, UFT, Palmas, TO, Brasil]

4 [Professor, Universidade Federal do Tocantins, UFT, Palmas, TO, Brasil. Diretor Regional, Associação Brasileira de Psiquiatria, ABP, Rio de Janeiro, RJ, Brasil. Coordenador do Serviço de Psiquiatria, Hospital Geral de Palmas, HGP, Palmas, TO, Brasil].

Chief Editor responsible for the article: Marsal Sanches

Authors contributions according to the Taxonomia CRediT: Ribeiro FV [1,2,3,5,6,7,8,11,12,13,14], Freitas RA [2,3,5,6,8,11,12,13,14], Nepomuceno VR [10,11,12,13,14], Baldaçara L [1,2,3,5,6,7,8,10,11,12, 13,14]

Disclosure of potential conflicts of interest: none

Funding: none

Approval Research Ethics Committee (REC): not applicable

Received on: 2025/07/28 | Accepted on: 2025/08/24 | Published on: 2025/09/19

How to cite: Ribeiro FV, Freitas RA, Nepomuceno VR, Baldaçara L. Analysis of interventions to reduce stigma related to mental disorder: a critical systematic review. Debates Psiquiatr. 2025;15:1-32. https://doi.org/10.25118/2763-9037.2025.v15.1493

Abstract

Objective: This review aimed to find and assess mental disorder stigma management solutions. Methods: The PROSPERO review ID is CRD42022369853 and followed the PRISMA protocol. This review recruited language-neutral publications from Scielo, Medline (via PubMed), and Google Scholar from 2019 to 2023. Three psychiatrists helped with selection, data collection and analysis, risk of bias assessment, and methodological quality rating. The ROBIS instrument assessed systematic review bias, while the Cochrane Handbook for Systematic Reviews of Interventions assessed CT bias. Use the Oxford Centre for Evidence-Based Medicine's 2011 Levels of Evidence to evaluate methodological quality. Following peer review. Results: Thirteen articles addressed stigma therapies for mental diseases like depression, anxiety, bipolar affective disorder, and schizophrenia. Audiovisual tools, theoretical and practical classes, and clinical case discussions reduced stigma, with evidence levels of 2–3. Studies found various drawbacks: a) some research did not focus on stigma reduction; b) data reporting was restricted. Conclusions: These findings show that stigma-reduction treatments must be continual and successful across varied intervention groups.

Keywords: stigma, intervention, mental disorders, systematic review, psychoeducation.

Resumo

Objetivo: Este estudo teve como objetivo encontrar e avaliar soluções para o gerenciamento do estigma em transtornos mentais. Métodos: O estudo PROSPERO ID é CRD42022369853 e seguiu o protocolo PRISMA. O estudo recrutou publicações de linguagem neutra do Scielo, Medline (via PubMed) e Google Acadêmico de 2019 a 2023. Três psiquiatras auxiliaram na seleção, coleta e análise de dados, avaliação do risco de viés e classificação da qualidade metodológica. O instrumento ROBIS avaliou o viés de revisão sistemática, enquanto o Cochrane Handbook for Systematic Reviews of Interventions avaliou o viés de TC. Utilizamos os Níveis de Evidência de 2011 do Oxford Centre for Evidence-Based Medicine para avaliar a qualidade metodológica. Após revisão por pares. Resultados: Treze artigos abordaram terapias de estigma para doenças mentais como depressão, ansiedade, transtorno afetivo bipolar e esquizofrenia. Ferramentas audiovisuais, aulas teóricas e práticas e discussões de casos clínicos reduziram o estigma, com níveis de evidência de 2 a 3. Estudos encontraram várias desvantagens: a) algumas pesquisas não se concentraram na redução do estigma; b) o relato de dados foi restrito. Conclusões: Essas descobertas mostram que os tratamentos para redução do estigma devem ser contínuos e bem-sucedidos em diferentes grupos de intervenção.

Palavras-chave: estigma, intervenção, transtornos mentais, revisão sistemática, psicoeducação.

Resumen

Objetivo: Este estudio tuvo como objetivo encontrar y evaluar soluciones para la gestión del estigma en los trastornos mentales. Métodos: El estudio PROSPERO, con su ID CRD42022369853, siguió el protocolo PRISMA. Se reclutaron publicaciones de lenguaje neutro de Scielo, Medline (vía PubMed) y Google Académico entre 2019 y 2023. Tres psiquiatras colaboraron en la selección, la recopilación y el análisis de datos, la evaluación del riesgo de sesgo y la calificación de la calidad metodológica. El instrumento ROBIS evaluó el sesgo de las revisiones sistemáticas, mientras que el Manual Cochrane para Revisiones Sistemáticas de Intervenciones evaluó el sesgo de las revisiones de TC. Se utilizaron los Niveles de Evidencia de 2011 del Centro de Medicina Basada en la Evidencia de Oxford para evaluar la calidad metodológica. Tras la revisión por pares, se obtuvieron resultados. Resultados: Trece artículos abordaron terapias para el estigma en enfermedades mentales como la depresión, la ansiedad, el trastorno afectivo bipolar y la esquizofrenia. Las herramientas audiovisuales, las clases teóricas y prácticas, y las discusiones de casos clínicos redujeron el estigma, con niveles de evidencia de 2 a 3. Los estudios encontraron diversas desventajas: a) algunas investigaciones no se centraron en la reducción del estigma; b) el reporte de datos fue limitado. Conclusiones: Estos hallazgos muestran que los tratamientos para la reducción del estigma deben ser continuos y exitosos en diversos grupos de intervención.

Palabras clave: estigma, intervención, trastorno mental, revisión sistemática, psicoeducación .

Introduction

Stigma, from a historical and theoretical perspective, originates from the ancient Greek verb "stizo," meaning “to mark as a sign of shame, punishment, or disgrace,” representing a socially undesirable characteristic. In contemporary society, stigma remains a prevalent issue, leading to discrimination and, consequently, a loss of dignity for individuals with mental disorders . This discrimination undermines the right to health, especially in nations with limited investment in mental health care, where people with mental disorders face higher morbidity and mortality rates compared to the general population .

Stigma negatively impacts mental health outcomes, including access to treatment, acceptance of therapeutic interventions, quality of life, and social inclusion. Societal and cultural stereotypes further perpetuate the marginalization of individuals with mental disorders, reducing their life expectancy and worsening their overall well-being. Research has shown that in countries with higher awareness of mental health, individuals are more likely to seek treatment .

Conversely, in low-resource settings, cultural beliefs and stigma contribute to a lack of recognition of mental health needs, preventing individuals from seeking the necessary care . Given the persistent nature of mental health stigma and its detrimental effects on individuals and society, this review seeks to address a crucial question: What are the most effective interventions for reducing and eliminating stigma associated with mental disorders? Understanding and implementing these interventions is essential for improving mental health care and reducing the social and economic burden of mental illness.

Then, the objective of this review is to identify and evaluate the effectiveness of interventions aimed at reducing and eliminating the stigma associated with mental disorders. This research aims to look at different methods that have been used to fight stigma in mental health by reviewing existing studies, with the goal of offering ideas that can help create effective and widely applicable solutions to improve mental health results and lessen social discrimination.

Methods

This systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and was registered in the PROSPERO database (CRD42022369853). The aim was to identify effective strategies to reduce the stigma associated with mental disorders.

Eligibility criteria: The inclusion criteria for the review encompassed systematic reviews with or without meta-analyses and clinical trials (CTs) published between January 2019 and December 2023. These studies had to focus on practical interventions for managing the stigma associated with mental disorders, providing statistical measures such as p-values, Odds Ratios (OR), Relative Risk (RR), and/or confidence intervals (CI). The exclusion criteria were other types of studies other than systematic reviews and clinical trials.

Search strategy, selection process, and data collection process: The search for relevant articles was conducted across multiple databases, including PubMed (via MEDLINE), Scielo, and Google Scholar. The primary search terms used were "stigma," "mental disorders," and "intervention." The selection process was carried out by two independent reviewers, with disagreements resolved by a third reviewer.

Data items and effect measures: type of intervention and reduction of stigma (reduction in stigma, measured by specific scales, attitudes, or behaviors).

Study risk of bias assessment and quality of evidence: The risk of bias was assessed using the ROBIS tool (Risk of Bias in Systematic Reviews) and the Cochrane Handbook for Systematic Reviews of Interventions. Additionally, the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence was used to evaluate the methodological quality of the studies included.

Synthesis methods: Data were registered by population (individuals with mental disorders or those affected by mental health-related stigma), type of intervention (strategies/interventions aimed at reducing stigma), and outcome (reduction in stigma, measured by specific scales, attitudes, or behaviors).

Results

Figure 1 (PRISMA flow diagram) illustrates the identification, screening, and inclusion process: Records identified: n = 1,021; records screened: n = 44; Studies included: n = 13. Risk of bias analysis is presented in Tables 1 and 2. Characteristics of excluded studies are presented in Table S1. Details about synthesis can be seen in Tables S2, S3, and S4.

The systematic review included 13 studies that examined interventions aimed at reducing the stigma associated with mental disorders, including depression, anxiety, bipolar disorder, and schizophrenia. The interventions were diverse, ranging from psychoeducation programs to biomedical message delivery and contact-based strategies.

Interventions on the stigma of mental disorders

Selected studies are presented in the Table 3.

A systematic review with an evidence level of 3 included articles that evaluated mental health literacy from non-randomized studies. In these studies, no outcome measurement methods were presented, providing little value for this part of the analysis .

A systematic review (SR) of small clinical trials (CTs) with interventions for mental health literacy and stigma among Latino adults in the USA showed that photo-novels on depression can increase knowledge and aim to reduce stigma and increase help-seeking intentions for treatment. In this study, participants were randomly recruited to read a photo novel or a text pamphlet, then answered a questionnaire (on reducing the stigma of mental healthcare) before and 1 month after. Better results were reported for the photo-novel intervention, with significantly greater reductions in mental health care stigma. In the post-test, the photo-novel group (t = 2.01, p < 0.05) and slightly, but not significantly, the text pamphlet group (t = 1.45, ns). At the 1-month follow-up, mental health stigma further decreased in the photo-novel group (t = 3.03, p < 0.05) and regressed toward baseline in the text pamphlet group, resulting in a significant difference between groups at the 1-month follow-up (t = 2.59, p < 0.05) .

Regarding the evaluation of the effectiveness of a school intervention aimed at improving mental health literacy and reducing stigma, an SR of CTs with an evidence level of 3 recruited 21 studies on mental health literacy for primary and secondary school students from Western countries and the USA . Studies with interventions involving video or contact with people who had experience with mental disorders reported a reduction in stigma among participants. The results presented after the intervention showed a statistical significance (p=0.03), but there was no difference at the 2.5-month follow-up, suggesting that the effects of the intervention were not sustained post-intervention .

Chisholm et al. , in their research with an evidence level of 2, recruited only CTs and included students aged between 12 and 13 years, who were allocated into two interventions: a) mental health education with contact with a young person with lived experience of mental illness; b) mental health education without contact. Measures were taken three weeks before, two weeks before, and six weeks after the intervention. Of the three topics addressed, only one was about mental illness stigma, and the Reported and Intended Behavior Scale (RIBS) was used to assess stigma-related behavior toward mental illness. Chisholm reported that they found a positive change in stigmatizing attitudes at follow-up but did not present statistical results .

Ojio et al. presented a study on a CT conducted in Tokyo, Japan, with a total of 179 high school, undergraduate, and graduate students. In the first stage, video lessons were used on the following topics: definition of mental illness and psychological symptoms, and then two groups were allocated to watch 10-minute video lessons. For one group, biomedical messages (BMM) and a film addressing the 'biological mechanisms of mental illnesses,' 'pharmacological mechanisms,' and 'gene-environment interaction.' For the other group, recommended messages (RCM) covered the following topics: a) high prevalence of mental illnesses; b) recovery-oriented messages; and c) messages on social inclusion/human rights . The Mental Illness Understanding Scale (MIDUS) was used in this study. The primary outcome was the effect of BMM on the reduction of useful knowledge about stigma related to mental illness, with an effect from the start until the post-test survey. Both groups showed improvement in MIDUS scores in the post-test survey, with similar effects [F (1.177) =160.5, p<0.0001, n2=0.48]. The effects of the interventions continued until the 1-year follow-up survey (B [95% CI] = -2.56 [-4.27, -0.85], p<0.01) and showed no difference between the groups .

A clinical trial conducted at the Guangzhou Psychiatric Hospital in China with senior community mental health professionals (unspecified occupation) participated in a training program that included three modules: 1st course, 2nd clinical practice, and 3rd combined public health perspective, stigma, and discrimination, adding WHO guidelines, ICD-10, and current policies. Li et al. reported that the following scales were used for evaluation: a) Mental Health Knowledge Schedule (MAKS), which assesses mental health knowledge related to stigma; b) Mental Illness: Clinicians' Attitudes Scale (MICA), which assesses stigmatizing attitudes; and c) Reported and Intended Behavior Scale (RIBS), which assesses reported and intended behavior related to mental health. Evaluation occurred before, after, 6 months after, and 12 months after the intervention. Regarding stigma in the pre-assessment, the scales showed no statistical difference between the intervention and control groups. The MAKS scale score increased more in the intervention group at 6 months and 12 months (p<0.05), 6 months 24.45 (2.37); 12 months, 24.17 (2.48) 95% CI. On the MICA scale, the intervention group decreased more than the control group (pre-test 49.79 and post-test 47.13), 6 months 44.21 (8.83), 12 months 45.20 (8.95) with 95% CI. After training, at 6 and 12 months, average RIBS scores increased more in the intervention group than the control group (p<0.001), posttest 13(2.71), 6 months 16.21 (2.89), 12 months 16.43 (3.28) 95% CI. . For more details, see Table 3.

Interventions to Address the Stigma of Depressive Disorder and Anxiety

Selected studies were inserted in the Table 4.

In a digital intervention aimed at mental health literacy for a specific subgroup, a systematic review (SR) study that included clinical trials (CTs). Its qualitative assessment reported that telehealth for depressive symptoms and stress evaluation had an acceptability rate of 95.2% among participants. The results showed that digital health interventions are effective through current digital technologies, leading to an improvement in young people's mental health. The results did not show a reduction in stigma as a primary outcome. In another CT study recruited for this SR, the result was p = 0.005 between pre- and post-test with online cognitive behavioral therapy (CBT); however, the primary outcome was depression reduction .

Mental Health First Aid Program Interventions: a) psychological first aid; b) suicide intervention skills training. These were applied in the public and private sectors to healthcare professionals, first responders, public servants, maintenance staff, government employees, housing association staff, managers, leaders, and the hospitality industry. In countries: Canada, Australia, Great Britain, Germany, Sweden, Spain, and Japan .

In a CT study recruited for this SR, an online psychoeducation program focused on depression and anxiety was evaluated, presented in a simple multimedia format containing graphics, videos from consumers with lived experiences of depression and anxiety, and exercises .

The statistical results revealed that for the intervention group compared to the control group participants, there was a decline in depression and anxiety stigma scores. Customized contrasts revealed a decline in depression and anxiety stigma scores for MH-Guru compared to control group participants from baseline to post-test and from baseline to 6-month follow-up (post-test: depression t = 6.4, p < 0.001; anxiety= 5.5, p < 0.001). 6 months: Depression (t = 2.8, p = 0.005); Anxiety (t = 4.1, p < 0.001). There were moderate effect sizes between the groups for depression and anxiety stigma at post-test (d = −0.56 and d = −0.42, respectively) and at 6 months (d = −0.47 and d = −0.42, respectively), where the negative effect corresponded to a reduction in stigma for the MH-Guru group .

Arthur et al. report the effectiveness of a mental health literacy program for community leaders in southern Ghana. A CT study with a total of 128 participants was divided into groups where the first part presented a) videos on myths and beliefs in mental disorders; b) real-life experiences of a person with depression and schizophrenia; c) a PowerPoint presentation of signs, symptoms, and treatment for depression and schizophrenia; and d) exploration of participants' prior knowledge about depression.

In the second part: problem solving and exercises, a depression vignette was presented where participants had to describe the image and what was happening behind it, functioning as a story. The control group received a basic leaflet on mental health issues written in simple language. A stigma questionnaire was administered (personal stigma and perceived stigma) . For personal stigma, the mean difference in personal stigma scores between groups at follow-up was 1.18 (95% CI: 3.51 to 1.14), and the size of the differences in mean scores was small (Cohen's d = 0.15, 95% CI: 0.22 to 0.53).

For perceived stigma, the mean difference in change in perceived stigma scores between the groups was 3.10 (95% CI: 5.63 to 0.57), and the magnitude of the difference in mean scores was (Cohen's d = 0.51, 95% CI: 0.13 to 0.89) . Table 4.

Interventions on the stigma of bipolar disorder and schizophrenia

Selected studies are presented in the Table 5.

Heim et al. , regarding contact interventions, the results were mixed. In one of the studies reviewed, a contact intervention was examined where a young person with schizophrenia was presented, along with a video featuring different individuals with schizophrenia. Despite reporting a statistically significant change in the pre-intervention and 1- month follow-up, the same results were not observed .

In another recruited CT, a face-to-face contact intervention was compared with a video-based contact intervention for mental health literacy among medical students . Both groups received an educational lecture before the contact intervention. A significant time effect emerged on the total score of the Opening Minds Stigma Scale for Health Care Providers (p < 0.001, partial η² = 0.49), but there was no statistically significant difference between the two conditions (video versus face-to-face) .

A CT was recruited for an RS study aiming to examine general practitioners' views and attitudes toward schizophrenia and the changes in their attitudes after anti-stigma education. A sample of 54 general practitioners began the session with interactive training and a slide presentation on the course, treatment, impact of stigma, and the role of the general practitioner . Another session followed with case discussions. A 16-item questionnaire focusing on doctors' opinions and attitudes toward schizophrenia was completed by participants before and after the intervention. Regarding the course of schizophrenia, 83% of general practitioners responded that patients with schizophrenia would recover their functionality. This number rose to 92.5% after the training sessions. Responses concerning a negative course decreased from 13.2% before the training to 7.5% (p = 0.2) during follow-up .

Kaur et al. highlighted a level 1 evidence study, an RS of studies with data collection, involving all types of stigma-related interventions in the mental health domain. Nine studies were included in this RS from regions of India, with participants being a) community members, b) healthcare workers, c) patients with schizophrenia and caregivers, d) women living with HIV/AIDS, and e) mental health professionals.

The interventions were a) case demonstration lecture, b) role play, c) mental health education workshops, and d) patient transport programs to specialized care .

There was no reduction in stigma as a primary outcome, but the results showed :

• Improved attitude among healthcare workers.
• Improved knowledge and attitude toward depression.

Fujii et al. reported on a CT with N = 115 that developed a scale for evaluating stigma in schizophrenia among community pharmacists in Aichi Province, Japan. The intervention group, consisting of 56 participants, underwent an educational program, attending a 60-minute lecture by a psychiatrist covering topics such as the concept, epidemiology, symptoms, the impact of the disease on social activities, diagnosis, and treatment. Another group of 59 participants engaged in the following activities: a) team presentation; b) lecture on mental disorder-related stigma; c) management of patients with schizophrenia; d) discussion to clarify patients' experiences; e) interview with a patient; f) discussion on the pharmacists' learning from patient experiences.

The evaluation used a stigma scale for schizophrenia among community pharmacists (SSCP), administered before the lecture (t1), after the lecture (t2), and after communication with diagnosed patients (t3). The effects of the contact-based educational program on reducing stigma were Factor I: Social distancing in professional pharmacy services and Factor II: Attitudes toward patients with a diagnosis of schizophrenia .

The total SSCP score was 9.0 (16.0 – 5.0) in the contact-based intervention group and 3.0 (7.0 – 1.0) in the educational lecture group (improvement rates of 15.5% and 5.2%, respectively; p < 0.001) . The improvement rates for each factor in the contact-based intervention and educational lecture groups were Factor I: 18.3% and 7.1%; Factor II: 23.0% and 4.5%; Factor III: 5.0% and 6.7%; Factor IV: 1.0% and 0%, respectively, revealing significant improvements in the scores for Factors I and II (p = 0.001 and p < 0.001, respectively) . Table 5.

Discussion

The present work, containing a critical analysis of systematic reviews and clinical trials, aimed to synthesize the main interventions for managing the stigma of mental disorders. Practical interventions for managing stigma are, from a public health perspective, important strategies to reduce the social and economic burden of mental disorders . Stigma is a barrier to help-seeking that contributes to the gap in mental health treatment, making effective strategies to reduce stigma vital .

Most of the studies combined education strategies with practical activities in addition to practical problem-solving activities . Educational interventions on mental health literacy are effective in improving individuals' attitudes toward people with mental illness, which, in turn, may lead to better outcomes for these individuals .

Other strategies observed were videos, presentations, problem-solving, professional training, demonstration lectures, role-play, mental health education workshops, and a patient transport program to specialized care .

Despite its limitations, this systematic review indicates that combined interventions can be effective in reducing stigma related to mental disorders. When analyzing methodological quality, level of evidence, and bias risk of the articles recruited for analysis, it was possible to find interventions with satisfactory results for training, literacy, and mental health education. To be effective, the intervention needs to be tailored to the targeted group (health professionals, community leaders, students, and families of people with mental disorders).

Moreover, the findings indicate that stigma is not restricted to a particular group of individuals; it exists even among those who work with people with mental disorders. The combination of training with theoretical and practical models showed positive results in all studies presented, regardless of the level of evidence and risk of bias.

Data showed results in long-term follow-up, with assessment periods ranging from the post-test to six months after the intervention. The importance of constant assessment and combining strategies over time to increase statistical robustness and effectively recognize the intervention's impact is clear. Given the results, it becomes evident that there must be a constant implementation of interventions aimed at reducing stigma, ensuring they are effective and replicable in various intervention groups.