Background There is a strong stigma attached to mental disorders preventing those affected from getting psychological help. The consequences of stigma are worse for racial and/or ethnic minorities compared to racial and/or ethnic majorities since the former often experience other social adversities such as poverty and discrimination within policies and institutions. This is the first systematic review and meta-analysis summarizing the evidence on the impact of differences in mental illness stigma between racial minorities and majorities. Methods This systematic review and meta-analysis included cross-sectional studies comparing mental illness stigma between racial minorities and majorities. Systematic searches were conducted in the bibliographic databases of PubMed, PsycINFO and EMBASE until 20th December 2018. Outcomes were extracted from published reports, and meta-analyses, and meta-regression analyses were conducted in CMA software. Results After screening 2787 abstracts, 29 studies with 193,418 participants (N = 35,836 in racial minorities) were eligible for analyses. Racial minorities showed more stigma than racial majorities (g = 0.20 (95% CI: 0.12 ~ 0.27) for common mental disorders. Sensitivity analyses showed robustness of these results. Multivariate meta-regression analyses pointed to the possible moderating role of the number of studies with high risk of bias on the effect size. Racial minorities have more stigma for common mental disorders when compared with majorities. Limitations included moderate to high risk of bias, high heterogeneity, few studies in most comparisons, and the use of non-standardized outcome measures. Conclusions Mental illness stigma is higher among ethnic minorities than majorities. An important clinical implication of these findings would be to tailor anti-stigma strategies related with mental illnesses according to specific racial and/or ethnic backgrounds with the intention to improve mental health outreach.

Background The evidence for the effectiveness of e-mental health interventions among ethnic minorities is still preliminary. This mixed methods study investigates the feasibility of a culturally adapted, guided online intervention with the intention to understand how it works and for whom to inform refinement. It also examines its likely effectiveness in reducing suicidal ideation when compared with the treatment as usual. Methods Turkish migrants with mild to moderate suicidal thoughts were recruited from the general population using social media and newspaper advertisements. The intervention group obtained direct access to a 6-week guided online intervention while participants in the waiting list condition had to wait for 6 weeks. The intervention is based on an existing online intervention and was culturally adapted. Participants in both conditions completed baseline, post-test, and follow-up questionnaires on suicidal ideation (primary outcome), depression, worrying, hopelessness, suicide attempt and self-harm, acculturation, quality of life, and usability. In addition, participants were interviewed to examine the feasibility and mechanisms of action in more depth. The responses were analysed by inductive thematic analysis. Results Eighty-five people signed up via the study website, and we included 18 (10 intervention, 8 waitlist control). While the therapeutic benefits were emphasised (e.g. feeling connected with the intervention), the feasibility was judged to be low. The main reasons given were not having severe suicidal thoughts and not being represented by the culturally adapted intervention. No suicide attempts were recorded during the study. The suicidal ideation, depression, and hopelessness scores were improved in both groups. Conclusion Although intended to be a definitive trial, the current study became a feasibility study with process evaluation to understand the components and how they operate. The online intervention was not superior to the control condition. Future studies need to attend the implementation issues raised including measures of stigma, acculturation, and careful cultural adaptations alongside more attention to coaching and relational support. They should also consider how to improve engagement alongside selection of those who are motivated to use online interventions and offer alternatives for those who are not. Trial registration Netherlands Trial Register, NTR5028. Registered on 1 March 2015

This study will be performed in two phases. First, the Dutch online intervention will be adapted to Turkish culture. The second phase will be a randomized controlled trial with two conditions: experimental and waiting-list control. Ethical approval has been granted for the trials in London and Amsterdam. The experimental group will obtain direct access to the intervention, which will take 6 weeks to complete. Participants in the waiting-list condition will obtain access to the modules after 6 weeks. Participants in both conditions will be assessed at baseline, post-test and 3 months post-test follow-up. The primary outcome measure is reduction in frequency and intensity of suicidal thoughts. Secondary outcome measures are self-harm, attempted suicide, suicide ideation attributes, depression, hopelessness, anxiety, quality of life, worrying and satisfaction with the treatment.

(2016) Canınakıymak -'crushing life energy': a qualitative study on lay and professional understandings of suicide and help-seeking among Turkish migrants in the UK and in the Netherlands, International Journal of Culture and Mental Health, 9:2, 182-196, DOI: 10.1080/17542863.2016 Currently, little is known about the views that Turkish migrants hold towards suicide, which may differ from the narratives held by native inhabitants of their host countries. Central to improving the provision of mental health services, furthering our knowledge of these views is important. The aim of this research was to explore Turkish cultural understandings on suicide and help-seeking for suicide. A qualitative study included data from 6 focus groups and 7 individual interviews with 38 Turkish-speaking lay people and 4 key informants living in the Netherlands or the UK during the year 2014/2015. Through the analysis of participants' stories and narratives, the following key themes emerged in relation to suicide: suicide as an escape from failure and as a failure in itself; acculturation orientation; parenting style; and shame and stigma. There were more similarities than differences between the themes among laypersons and key informants from two countries. Canına kıymak (crushing life energy) was a strong metaphor for personal distress. Suicide was perceived as a failing of responsibilities towards the family and community. Future research should aim to give voice to all ethnocultural groups to further the present understanding of suicide and help-seeking processes in these communities. ARTICLE HISTORY

Background There is a strong stigma attached to mental disorders preventing those affected from getting psychological help. The consequences of stigma are worse for racial and/or ethnic minorities who often experience other social adversities such as poverty and discrimination within policies and institutions. This is the first systematic review and meta-analysis summarizing the evidence on the impact of differences in mental illness stigma between racial minorities and majorities.Methods This systematic review and meta-analysis included cross-sectional studies comparing mental illness stigma between racial minorities and majorities. Systematic searches were conducted in the bibliographic databases of PubMed, PsycINFO and EMBASE until 20th December 2018. Outcomes were extracted from published reports, meta-analyses and meta-regression analyses were conducted in CMA software.Results After screening 2,787 abstracts, 29 studies with 193,418 participants (N=35,836 in racial minorities) were eligible for analyses. Racial minorities showed more stigma than racial majorities (g=0.20 (95% CI: 0.12~0.27) for common mental disorders. Sensitivity analyses showed robustness of these results. Multivariate meta-regression analyses pointed to the possible moderating role of the number of studies with high risk of bias on the effect size. Racial minorities have more stigma for common mental disorders when compared with majorities. Limitations included moderate to high risk of bias, high heterogeneity, few studies in most comparisons, and the use of non-standardized outcome measures.Conclusions An important clinical implication of these findings would be to tailor anti-stigma strategies according to specific racial and/or ethnic backgrounds with the intention to improve mental health outreach. These limitations suggest a need for more high quality research on stigma.

QuestionDigital interventions based on cognitive–behavioural therapy (iCBT) is associated with reductions in suicidal ideation. However, fine-grained analyses of effects and potential effect-moderating variables are missing. This study aimed to investigate the effectiveness of iCBT on suicidal ideation, effect moderators, effects on suicide attempts and predictors of adherence.Study selection and analysisWe systematically searched CENTRAL, PsycINFO, Embase and PubMed for randomised controlled trials that investigated iCBT for suicidal ideation or behaviours. Participants reporting baseline suicidal ideation were eligible. We conducted a one-stage individual participant data (IPD) meta-analysis. Suicidal ideation was the primary outcome, analysed as three indices: severity of suicidal ideation, reliable changes and treatment response.FindingsWe included IPD from nine out of ten eligible trials (2037 participants). iCBT showed significant reductions of suicidal ideation compared with control conditions across all indices (severity: b=−0.247, 95% CI −0.322 to −0.173; reliable changes: b=0.633, 95% CI 0.408 to 0.859; treatment response: b=0.606, 95% CI 0.410 to 0.801). In iCBT, the rate of reliable improvement was 40.5% (controls: 27.3%); the deterioration rate was 2.8% (controls: 5.1%). No participant-level moderator effects were identified. The effects on treatment response were higher for trials with waitlist-controls compared with active controls. There were insufficient data on suicide attempts. Human support and female gender predicted treatment adherence. The main source of potential bias was missing outcome data.ConclusionsThe current evidence indicates that iCBT is effective in reducing suicidal ideation irrespective of age, gender and previous suicide attempts. Future studies should rigorously assess suicidal behaviour and drop-out reasons.

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