Mental health training for clinicians reduces stigma, improves diagnostic accuracy
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Two separate efforts, both involving training and education interventions for health care workers, show promise in reducing stigma and improving care for patients with mental health conditions, data show.
“Mental health issues are widespread, affecting 20% of U.S. adults each year,” Lunarosa Peralta, MPH, a senior evaluation consultant in the Kaiser Permanente Care Management Institute Center for Evaluation and Analytics, and colleagues wrote. “Patient-facing workers in health care regularly interact with individuals with mental health issues ranging from situational stress and anxiety to more severe and chronic conditions. Few patient-facing workers receive training about mental health issues or how to respond effectively when patients and family members exhibit symptoms.”
Mental Health First Aid
The first intervention, Mental Health First Aid (MHFA), was described in a commentary published in the New England Journal of Medicine Catalyst. Peralta and colleagues provided MHFA classes to 817 clinical and nonclinical patient-facing health care workers. The classes were developed in Australia in 2001 for the general public. They involved evidence-based interactive public education that provided participants with skills to appropriately care for those who may develop a mental health problem or experience a crisis.
The training involved an 8-hour face-to-face class in one of 46 Kaiser Permanente medical centers or office buildings in 2018. The instructors customized the MHFA curriculum to make it more relevant to patient-facing health care workers. Participation was voluntary and health care workers were asked to complete a survey on their health beliefs and literacy before and after the training.
Among the 817 workers who participated, 71% completed the survey prior to training, 52% completed the survey immediately after training and 28% completed the survey 3 months after training. Most participants (80%) had no or minimal prior mental health training and held a patient-facing role (84%); 45% were nurses, 94% were union-represented employees and 90% were women, according to Peralta and colleagues.
Overall, the researchers reported that participants experienced “statistically significant improvements” in knowledge, stigmatizing perceptions and confidence in taking actions related to mental health problems, which were sustained at 3 months. Also, 98% of respondents who completed the survey after the training reported that they would recommend MHFA to others.
Karen Franchino, MSW, MPH, a national mental health and wellness senior consultant at Kaiser Permanente, told Healio Primary Care that “mental health trainings can help health care workers feel less fearful and more confident in their interactions with patients and members.”
“Health care workers can use their increased awareness and new skills to notice the signs that someone might be in distress, to deescalate stressful situations when needed and compassionately guide individuals to appropriate care,” she added.
The training has been expanded to Kaiser Permanente’s network of mental health advocates, according to Franchino.
Collaborating with individuals who have a mental illness
In a separate study published in JAMA Network Open, Brandon A. Kohrt, MD, PhD, an assistant professor of psychiatry, global health and cultural anthropology at Duke University, and colleagues examined the feasibility and acceptability of an anti-stigma mental health training intervention for primary care practitioners in Nepal. The researchers chose Nepal specifically since it is a low-resource setting.
“We first set out to reduce the stigma associated with mental illness with the idea that these [primary care practitioners] would be more willing to deliver mental health services,” Kohrt told Healio Primary Care.
In a pilot cluster randomized clinical trial conducted from Feb. 7, 2016, to August 10, 2018, Kohrt and colleagues randomly assigned practitioners from 17 different practices into a control group (n = 45) or intervention group (n = 43). The intervention focused on changing primary care practitioners’ attitudes on mental health by listening to people with lived experience of mental illness (PWLE) share their stories. PWLE presented recovery testimonials in the form of photographic narratives. The intervention incorporated the WHO Mental Health Gap Action Programme Intervention Guide (mhGAP), a training initiative for primary care-based mental health services in low-resource settings, according to Kohrt and colleagues. PWLE participated as cofacilitators in the 40-hour mhGAP training. Meanwhile, the control group was trained with mhGAP without PWLE cofacilitators.
The researchers used the Social Distance Scale (SDS) to determine practitioners’ accuracy of diagnoses of mental illness; decreases in scores signaled lower stigma. Primary care practitioners’ SDS scores were assessed at 4 months and 16 months following the training.
Among the participating practitioners, 85.2% were men and their mean age was 36.2 years. Overall, 76.7% in the intervention group and 73.3% in the control group completed the training. Also, 73.3% of the PWLE cofacilitators completed the training.
Primary care practitioners in the intervention group exhibited a diagnosis accuracy of 72.5% compared with 34.5% in the control group. The intervention group experienced a mean reduction in stigma of 10.6 SDS points (95% CI, 14.5-6.74) compared with a decrease of 2.8 SDS points (95% CI, 8.29-2.7) in the control group.
The findings suggest that the intervention “may have the potential to reduce stigma among [primary care practitioners] without introducing substantial risk of harm to PWLE collaborating in trainings,” Kohrt and colleagues wrote.
“We were surprised and quite happy to see potential benefits [of the intervention], not only with improving stigma but also making clinicians better able to accurately identify who may have a mental illness,” Kohrt said.
A continuation of this research in a larger, randomized clinical trial has been initiated in Nepal. The trial will include more than 270 clinicians and more than 1,000 patients to test the large-scale capabilities of the intervention, according to Kohrt.
In a related commentary, Karina W. Davidson, PhD, MASc, the director of the Institute of Health System Science at Feinstein Institutes for Medical Research, discussed the impact reducing stigma among primary care practitioners can have on patient care.
“It is possible that reducing stigmatizing attitudes by primary care clinicians through educational training could ultimately improve other aspects of care received by this large subpopulation of patients,” she wrote.
If left unchecked, stigmatizing attitudes regarding mental illness can have a “potentially deleterious impact on the quality and effectiveness of primary care provided,” Davidson wrote.
References:
Davidson KW. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.31512.
Kohrt BA, et al. JAMA Netw Open. 2021;doi:10.1001/jamanetworkopen.2021.31475.
Peralta L, et al. NEJM Catalyst. 2021;doi:10.1056/CAT.20.0623.