Discrimination Amongst People With Mental Illness
The MIRIAD (Mental Illness-Related Investigations on Discrimination) study was a cross-sectional study of 200 individuals using secondary mental health services in South London. Data were collected between September 2011 and October 2012. The study was approved by the East of England/Essex 2 Research Ethics Committee (ref 11/EE/0052).
Inclusion criteria were: aged at least 18 years; a clinical diagnosis of either Major Depression, Bipolar or Schizophrenia spectrum disorders; self-defined Black, White or Mixed (Black and White) ethnicity; current treatment with a community mental health team (CMHT); sufficiently fluent in English to provide informed consent; and sufficiently well for participation to not pose a risk to their or others' health or safety. We did not include Asian ethnicities due to low prevalence numbers in the target area.
Clinicians were provided with a list of eligible service users and asked if the service user was sufficiently well to participate. A letter was posted to eligible service users inviting them to contact the research team if they were interested in participating. This letter was followed by a reminder flyer if there had been no response within one month.
Research Assistants interviewed participants usually over two sessions (range 1–4). Participants received £15 ($23 USD) per sitting for their time. The interview schedule collected demographic and clinical information and contained a battery of measures on stigma, discrimination and access to physical and mental health care; those relevant to this paper are detailed below. Clinical data were extracted from patient records.
Discrimination and Stigma Scale (DISC): an interviewer-delivered measure of experiences of discrimination ('unfair treatment') in the last 12 months due to a diagnosis of a mental illness. Participants report experiences of discrimination across 21 areas including employment, dating or intimate relationships, on a 4-point Likert scale. The DISC has good psychometric properties. A 'severity' score (range 0–3) was calculated by adding each item score and dividing by the number of applicable, non-missing items. A count score (range 0–21) was calculated by counting the number of items where the participant reported any degree of discrimination.
Questionnaire on Anticipated Discrimination (QUAD): a self-complete measure comprising 14 items assessing the extent to which participants expect to be treated unfairly in areas of life similar to the DISC. Each item is scored on a 4-point Likert scale ranging from 0 (Strongly disagree) to 3 (Strongly agree). Psychometric analyses indicate good internal consistency and construct validity. A 'severity' score (range 0–3) was calculated by adding each item score and dividing by the number of applicable, non-missing items. A count score of the number life areas of anticipated discrimination was calculated.
The Brief Psychiatric Rating Scale (BPRS;): comprises 18 items addressing symptomatology. The scale is widely used and is reliable and valid. Three subscales were calculated according to established criteria: Anxiety & Depression, Hostility & Suspiciousness, and Thinking & Perception.
Global Assessment of Functioning (GAF;) captured current functioning rated by the service users' main professional caregiver. Rated on a scale of 0–100, it is the most frequently used measure of functioning in the mental health field and has good validity and inter-rater reliability.
Beck Hopelessness Scale (BHS;): is a self-complete measure assessing hopelessness. The version used in this study had a 5-point Likert (ranging from 1 'strongly agree' to 5 'strongly disagree') on 20 items. A total score was calculated by summing the items (possible range 20 to 100).
Internalised Stigma of Mental Illness Scale (ISMI;): a 29-item measure measuring service users' experience of internalised stigma, rated on a 4-point Likert scale. Strong internal consistency and test–retest reliability have been reported. There are five subscales including a five item 'Discrimination Experience' subscale, which due to being conceptually similar to the DISC was excluded. A total score was generated by summing the remaining 24 items.
Multigroup Ethnic Identity Scale (MEIM;): a 12 item self-report measure of Ethnic identity, two items rated on a 5-point Likert scale and remaining ten on a 4-point Likert Scale. It has good psychometric properties.
Analyses used Stata version 11. Rates of experienced and anticipated discrimination overall and by life area were assessed using frequency analyses. The relationship between experienced and anticipated discrimination was assessed with Spearman's rho due to the non-normality of data. Associations between demographic characteristics and severity of experienced and anticipated discrimination were investigated using robust multiple regression to account for non-normality of data. These analyses additionally adjusted for the degree of functioning and symptomatology. Variables were omitted from final models if found not to contribute significantly using likelihood ratio tests. After these preliminary analyses, we conducted post-hoc analyses to test emerging hypotheses regarding the findings. We examined rates of experienced discrimination by ethnic identity and internalised stigma using ANOVA tests.
Methods
The MIRIAD (Mental Illness-Related Investigations on Discrimination) study was a cross-sectional study of 200 individuals using secondary mental health services in South London. Data were collected between September 2011 and October 2012. The study was approved by the East of England/Essex 2 Research Ethics Committee (ref 11/EE/0052).
Recruitment and Sample
Inclusion criteria were: aged at least 18 years; a clinical diagnosis of either Major Depression, Bipolar or Schizophrenia spectrum disorders; self-defined Black, White or Mixed (Black and White) ethnicity; current treatment with a community mental health team (CMHT); sufficiently fluent in English to provide informed consent; and sufficiently well for participation to not pose a risk to their or others' health or safety. We did not include Asian ethnicities due to low prevalence numbers in the target area.
Clinicians were provided with a list of eligible service users and asked if the service user was sufficiently well to participate. A letter was posted to eligible service users inviting them to contact the research team if they were interested in participating. This letter was followed by a reminder flyer if there had been no response within one month.
Data Collection
Research Assistants interviewed participants usually over two sessions (range 1–4). Participants received £15 ($23 USD) per sitting for their time. The interview schedule collected demographic and clinical information and contained a battery of measures on stigma, discrimination and access to physical and mental health care; those relevant to this paper are detailed below. Clinical data were extracted from patient records.
Discrimination and Stigma Scale (DISC): an interviewer-delivered measure of experiences of discrimination ('unfair treatment') in the last 12 months due to a diagnosis of a mental illness. Participants report experiences of discrimination across 21 areas including employment, dating or intimate relationships, on a 4-point Likert scale. The DISC has good psychometric properties. A 'severity' score (range 0–3) was calculated by adding each item score and dividing by the number of applicable, non-missing items. A count score (range 0–21) was calculated by counting the number of items where the participant reported any degree of discrimination.
Questionnaire on Anticipated Discrimination (QUAD): a self-complete measure comprising 14 items assessing the extent to which participants expect to be treated unfairly in areas of life similar to the DISC. Each item is scored on a 4-point Likert scale ranging from 0 (Strongly disagree) to 3 (Strongly agree). Psychometric analyses indicate good internal consistency and construct validity. A 'severity' score (range 0–3) was calculated by adding each item score and dividing by the number of applicable, non-missing items. A count score of the number life areas of anticipated discrimination was calculated.
The Brief Psychiatric Rating Scale (BPRS;): comprises 18 items addressing symptomatology. The scale is widely used and is reliable and valid. Three subscales were calculated according to established criteria: Anxiety & Depression, Hostility & Suspiciousness, and Thinking & Perception.
Global Assessment of Functioning (GAF;) captured current functioning rated by the service users' main professional caregiver. Rated on a scale of 0–100, it is the most frequently used measure of functioning in the mental health field and has good validity and inter-rater reliability.
Beck Hopelessness Scale (BHS;): is a self-complete measure assessing hopelessness. The version used in this study had a 5-point Likert (ranging from 1 'strongly agree' to 5 'strongly disagree') on 20 items. A total score was calculated by summing the items (possible range 20 to 100).
Internalised Stigma of Mental Illness Scale (ISMI;): a 29-item measure measuring service users' experience of internalised stigma, rated on a 4-point Likert scale. Strong internal consistency and test–retest reliability have been reported. There are five subscales including a five item 'Discrimination Experience' subscale, which due to being conceptually similar to the DISC was excluded. A total score was generated by summing the remaining 24 items.
Multigroup Ethnic Identity Scale (MEIM;): a 12 item self-report measure of Ethnic identity, two items rated on a 5-point Likert scale and remaining ten on a 4-point Likert Scale. It has good psychometric properties.
Data Analysis
Analyses used Stata version 11. Rates of experienced and anticipated discrimination overall and by life area were assessed using frequency analyses. The relationship between experienced and anticipated discrimination was assessed with Spearman's rho due to the non-normality of data. Associations between demographic characteristics and severity of experienced and anticipated discrimination were investigated using robust multiple regression to account for non-normality of data. These analyses additionally adjusted for the degree of functioning and symptomatology. Variables were omitted from final models if found not to contribute significantly using likelihood ratio tests. After these preliminary analyses, we conducted post-hoc analyses to test emerging hypotheses regarding the findings. We examined rates of experienced discrimination by ethnic identity and internalised stigma using ANOVA tests.
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