Lawrence H Yang
Vice Chair and Associate Professor of Social and Behavioral Sciences
Associate Director, Global Center for Implementation Science
Founding Director, Global Mental Health and Stigma Program
Dr. Larry Yang is currently Associate Professor and Vice Chair of the Department of Social and Behavioral Sciences; Associate Director of the Global Center for Implementation Science at NYU; and Founding Director of NYU’s Global Mental Health and Stigma Program. He is also PI of a generous donor gift from the Li Ka Shing Foundation to fund an initiative to promote Global Mental Health and Wellness via GPH activities.
Dr. Yang has received extensive interdisciplinary training, including clinical psychology (Boston University), psychiatric epidemiology (Columbia University) and medical anthropology (Harvard University). Dr. Yang has received eight early career awards in stigma, six of which are national. Most recently (2021), Dr. Yang was awarded the Maltz Prize for Innovative and Promising Schizophrenia Research (Brain and Behavior Research Foundation). Regarding scholarship, Dr. Yang currently has >120 peer-reviewed publications, including in leading medical and public health journals such as JAMA Psychiatry, British Journal of Psychiatry, and the American Journal of Public Health. Regarding currently-funded NIH grants, he is PI of three separate R01 grants (described below), including a 3-year supplement; is PI of an R21 grant; and is co-investigator on 3 R01 grants and another R34 grant.
Research Narrative: If every public health researcher had a calling card indicator, Dr. Larry Yang's would be stigma.
What began as a curiosity to think, study and write about his own culture -- Chinese culture and its influences on the manifestation of stigma -- drove the GPH Associate Professor to develop a framework for how stigma acts to impede social recovery that could be applied to cultural groups worldwide to improve the lives of countless people with mental illness and their families around the world.
"I was drawn by the global, research, and practice perspective of GPH. I saw working at GPH as an incredible research opportunity to build global mental health programs and research in implementation science" said Larry regarding his position on the GPH Social and Behavioral Sciences faculty. As part of the faculty, Larry regularly teaches Psychometric Measurement and Analysis. In addition to teaching and his Vice Chair duties, Larry also acts as Associate Director of the Global Center for Implementation Science (Director: Donna Shelley) and as Founding Director of the Global Mental Health and Stigma Program. Larry also conducts several ongoing research studies on the forefront of public health, psychiatric epidemiology and implementation science.
Larry's fascination with stigma was first sparked during his dissertation research in Beijing with a leader in global mental health research, Michael Phillips. "I saw stigma in its most terrifying and ferocious form," said Larry describing his first experiences working with people with serious mental health in Beijing. "For the family members and those with mental illness themselves, it's crippling and debilitating. What 'face' (a crucial Chinese concept) allows you to do is to plug into social networks and enables you to access social resources. Just imagine if you are cut off from any social resource? You have no power to access the common things that most people do in their everyday lives." From this experience, Larry became motivated to empower people with mental illness and their families within their communities.
After receiving an NIMH K-award (2005-2010), Larry conducted a study in New York City of the psychological factors, including stigma, that shape the course of mental illness among Chinese immigrants. Larry formulated theoretical work on how culture relates to stigma (i.e. the “What Matters Most” framework) and implementing interventions to improve recovery for differing stigmatizing conditions. He learned that upholding face (to achieve lineage obligations) is important among Chinese immigrants, as it is for Asians in many countries. When someone develops signs of mental illness, that person loses face in many circumstances. Larry used the study to formulate an anti-stigma intervention to help people with mental illness take a powerful step towards regaining face. Illustrating how this framework could inform global programs, Larry then applied the ‘what matters most’ perspective to address HIV stigma in Botswana. Larry identified that “womanhood” in Botswana is signified by “bearing and caring for children” (AJPH, 2021). These cultural imperatives bring pregnant women into contact with free antenatal services, including routine HIV testing, where their HIV status is discovered before their male partners. National HIV healthcare policies thereby unintentionally reinforce disadvantage among women with HIV, whereby men delay or avoid testing by using their partner’s status as a proxy for their own, leading women diagnosed with HIV to be blamed and stigmatized. Larry used this theoretical framework in a recently-completed NIMH-funded R21 grant (R21 TW011084-01) to implement a pragmatic clinical trial evaluating an intervention to counter culturally-salient aspects of HIV stigma that impede anti-retroviral treatment adherence and antenatal care in Botswana among pregnant women with HIV. This stigma intervention, by building upon the perspective that a woman in Botswana who achieves ‘what matters most’ (i.e., who bears and cares for children) can be protected from HIV stigma, has shown promising results. Larry seeks to expand this intervention into a cluster randomized clinical trial to facilitate potential national scale-up in Botswana. Larry also participated as a Scientific member of the “NIH Office of AIDS Research & NIMH HIV-Related Intersectional Stigma” Working Group (2020) to set priorities in this area.
Larry has advanced his research in China as PI of two separate NIMH-funded R01 studies (R01MH108385; R01 MH127631) with co-PI's, Michael Phillips, William Stone and Matcheri Keshavan, seeking to characterize the cognition of completely untreated psychosis in China. Recently, China has been implementing programs in detection of untreated psychosis around the country. As the program had not yet reached the poorest provinces in China, Larry chose to propose a study in the rural provinces of China. The study seeks to enroll 400 untreated psychosis participants, who are then matched with 400 treated psychosis participants and an additional 400 healthy control participants in rural China. The first publication from this R01 data shows that cognitive performance may continue to decrease as the duration of untreated psychosis becomes prolonged (JAMA Psychiatry, 2020), thus potentially shifting the scientific thinking about schizophrenia by suggesting possible novel neurodegenerative processes in the natural course of chronic psychosis. A 3-year Supplement adds examination of the neurobiological markers of untreated psychosis to validate three psychosis subgroups that exhibit neurobiologically distinct differences (or ‘biotypes’). A follow-up longitudinal, 5-year R01 proposal to capitalize upon this rare cohort has been recently funded by NIMH.
Relevant to global mental health and implementation science, Larry is leading a project to help address the mental health treatment gap—i.e., the proportion of people who need but do not receive care for mental disorders--which is disproportionately high in low- and middle-income countries. As a promising strategy, there has been a call for a scale-up of mental health servicesvia ‘task sharing’ or delegating the provision of mental health care to a broader cadre of nonspecialists (e.g., community health workers). Yet, there remains a lack of critical knowledge on how to successfully implement and scale-up task-sharing mental health strategies in real-world settings. Larry is PI of a third NIMH-funded R01 (with co-PI, Judy Bass; R01 MH122851) to validate a newly-developed multi-dimensional measure that enables rapid assessment of modifiable critical factors affecting the implementation of task sharing mental health strategies. Prior developmental work took place using well-established implementation science frameworks and qualitative data from four previous, NIMH-funded global regional networks (2011-2016). Larry co-led, with Judy Bass, the “Shared Research Project”, where they examined the barriers and facilitators to scale-up task-sharing interventions spanning 4 global hubs (i.e., Latin America, focusing on Chile, Brazil, and Argentina; Africa, and; India/ Pakistan). Via this funded R01 (R01 MH122851), the study team will validate this measure within three additional, ongoing NIMH-funded task-sharing mental health programs in South Africa, Chile, and Nepal. This project promises to identify modifiable barriers and facilitators to improve implementation effectiveness globally and within the U.S, and advances the aims of the Global Center for Implementation Science, where Larry holds a leadership position.
BA, High Honors and Phi Beta Kappa, Wesleyan University, Middletown, CTPhD, Boston University, Boston, MAClinical Fellowship, Harvard Medical School (Massachusetts Mental Health Center)Postdoctoral Fellowship, Columbia Mailman School of Public Health (NIMH funded T32 Training Program in Psychiatric Epidemiology)
Maltz Prize for Innovative and Promising Schizophrenia Research -- Brain and Behavior Research Foundation (2021)NIH Fellow-Training Institute for Dissemination & Implementation Research in Health (TIDIRH) (2019)Fellow (Elected), American Psychopathological Association (2018)Award for Emerging Leadership, Americal Psychological Association (2012)Award for Advancing Minority Mental Health, American Psychiatric Foundation (2012)Young Investigator Award, NARSAD/ Brain and Behavior Foundation (2010)Emerging Leader Award for Significant Contributions to the Advancement of Ethnic Minority Psychology, American Psychological Association (2010)Calderone Award for Junior Faculty, Columbia University School of Public Health (2009)REACH for the R01 Award, Columbia University Irving Institute for Clinical and Translational Research (2009)Early Career Research Award, American Psychological Association (2008)Early Career Award, Asian American Psychological Association (2008)Dalmas A. Taylor Outstanding Student Dissertation Award, American Psychological Association (Division of Clinical Psychology- Ethnic Minority Focus) (2002)Outstanding Dissertation Award, American Psychological Association (Division of International Psychology) (2002)
Cognition and PsychosisCommunity HealthCultural Determinants of HealthEarly Intervention and PsychosisGlobal HealthImplementation scienceMedical AnthropologyMental HealthMinoritiesMinority HealthPsychiatric EpidemiologyPsychologyStigma and Intersectional Stigma“At-Risk” States for Psychosis
Barriers and facilitators to implementation of evidence-based task-sharing mental health interventions in low- and middle-income countries: a systematic review using implementation science frameworksLe, P. T. D., Eschliman, E. L., Grivel, M. M., Tang, J., Cho, Y. G., Yang, X., Tay, C., Li, T., Bass, J., & Yang, L. H.
Journal titleImplementation Science
Issue1AbstractBackground: Task-sharing is a promising strategy to expand mental healthcare in low-resource settings, especially in low- and middle-income countries (LMICs). Research on how to best implement task-sharing mental health interventions, however, is hampered by an incomplete understanding of the barriers and facilitators to their implementation. This review aims to systematically identify implementation barriers and facilitators in evidence-based task-sharing mental health interventions using an implementation science lens, organizing factors across a novel, integrated implementation science framework. Methods: PubMed, PsychINFO, CINAHL, and Embase were used to identify English-language, peer-reviewed studies using search terms for three categories: “mental health,” “task-sharing,” and “LMIC.” Articles were included if they: focused on mental disorders as the main outcome(s); included a task-sharing intervention using or based on an evidence-based practice; were implemented in an LMIC setting; and included assessment or data-supported analysis of barriers and facilitators. An initial conceptual model and coding framework derived from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework was developed and iteratively refined to create an integrated conceptual framework, the Barriers and Facilitators in Implementation of Task-Sharing Mental Health Interventions (BeFITS-MH), which specifies 37 constructs across eight domains: (I) client characteristics, (II) provider characteristics, (III) family and community factors, (IV) organizational characteristics, (V) societal factors, (VI) mental health system factors, (VII) intervention characteristics, and (VIII) stigma. Results: Of the 26,935 articles screened (title and abstract), 192 articles underwent full-text review, yielding 37 articles representing 28 unique intervention studies that met the inclusion criteria. The most prevalent facilitators occur in domains that are more amenable to adaptation (i.e., the intervention and provider characteristics domains), while salient barriers occur in domains that are more challenging to modulate or intervene on—these include constructs in the client characteristics as well as the broader societal and structural levels of influence (i.e., the organizational, mental health system domains). Other notable trends include constructs in the family and community domains occurring as barriers and as facilitators roughly equally, and stigma constructs acting exclusively as barriers. Conclusions: Using the BeFITS-MH model we developed based on implementation science frameworks, this systematic review provides a comprehensive identification and organization of barriers and facilitators to evidence-based task-sharing mental health interventions in LMICs. These findings have important implications for ongoing and future implementation of this critically needed intervention strategy, including the promise of leveraging task-sharing intervention characteristics as sites of continued innovation, the importance of but relative lack of engagement with constructs in macro-level domains (e.g., organizational characteristics, stigma), and the need for more delineation of strategies for task-sharing mental health interventions that researchers and implementers can employ to enhance implementation in and across levels. Trial registration: PROSPERO CRD42020161357
Coronavirus Disease (COVID-19) Related Discrimination and Mental Health in Five U.S. Southern CitiesLe, P. T. D., Misra, S., Hagen, D., Wang, S. M., Li, T., Brenneke, S. G., Yang, L. H., & Goldmann, E.
Journal titleStigma and HealthAbstractEvidence is mounting that stigma and discrimination related to coronavirus disease (COVID-19) disproportionately impact racial/ethnic minority groups, and that these experiences can worsen mental health. The present study sought to examine multiple types of COVID-related discrimination and their associations with mental health outcomes among racial/ethnic groups in the U.S. South, a region characterized by high levels of racial polarization and increasingly large numbers of undocumented immigrants.We used the cross-sectional, population-based COVID-19 Southern Cities Study (5/26/20–6/6/20) of n = 1,688 adults in Atlanta-GA, Austin-TX, Dallas-TX, Houston-TX, and New Orleans-LA. Three adapted scales (Everyday Discrimination, Major Discrimination, Heightened Vigilance) assessed self-reported COVID-related discrimination. Mental health outcomes included psychological distress, sleep troubles, physical reactions, and self-rated worsened mental health. Bivariable comparisons and adjusted logistic regression models were conducted. The study found that major discrimination was more common (p < .001) among Hispanic and non-Hispanic Black than non-Hispanic Asian and non-Hispanic White respondents. All racial/ethnic minority groups experienced more everyday discrimination (p = .004) and heightened vigilance due to anticipated discrimination (p < .001) than non-Hispanic White respondents. All discrimination types were associated with all mental health outcomes (Odds Ratio; OR range: 1.63–2.61) except everyday and major discrimination with sleep troubles. Results showing greater COVID-related discrimination for racial/ethnic minority groups confirm that these discrimination experiences are not solely about the infectious disease itself, but also entrenched with persistent racism. Responses to COVID-related discrimination should also consider long-lasting impacts on mental health for racial/ethnic minority groups even after the immediate pandemic ends.
Determinants of never-treated status in rural versus urban contexts for individuals with schizophrenia in a population-based study in ChinaYang, L. H., Phillips, M. R., Li, X., Yu, G., Grivel, M. M., Zhang, J., Shi, Q., Ding, Z., Pang, S., & Susser, E.
Journal titleBMC psychiatry
Issue1AbstractBackground: A goal of China’s 2012 National Mental Health Law is to improve access to services and decrease urban versus rural disparities in services. However, pre-reform data is needed for objective evaluation of these reforms’ effectiveness. Accordingly, this study compares the pre-reform utilization of medical services for the treatment of schizophrenia in rural and urban communities in China. Methods: In a large community-based study in four provinces representing 12% of China’s population conducted from 2001 to 2005, we identified 326 individuals with schizophrenia (78 never treated). Comparing those living in urban (n = 86) versus rural (n = 240) contexts, we used adjusted Poisson regression models to assess the relationship of ‘never treated’ status with family-level factors (marital status, family income, and number of co-resident family members) and illness severity factors (age of onset, symptom severity and functional impairment). Results: Despite similar impairments due to symptoms, rural patients were less likely to have received intensive mental health services (i.e., use psychiatric inpatient services), and appeared more likely to be ‘never treated’ or to only have received outpatient care. Among rural patients, only having more than four co-resident family members was independently associated with ‘never-treated’ status (RR = 0.34; 95% CI, 0.12–0.94; p = 0.039). Among urban patients, only older age of onset was independently associated with ‘never-treated’ status (RR = 1.06; 95% CI 1.02–1.10, p = 0.003). Conclusions: Identifying differential drivers of service utilization in urban and rural communities is needed before implementing policies to improve the utilization and equity of services and to define metrics of program success.
Effectiveness of enhancing contact model on reducing stigma of mental illness among family caregivers of persons with schizophrenia in rural China: A cluster randomized controlled trialRan, M. S., Wang, Y. Z., Lu, P. Y., Weng, X., Zhang, T. M., Deng, S. Y., Li, M., Luo, W., Wong, I. Y. L., Yang, L. H., Thornicroft, G., & Lu, L.
Journal titleThe Lancet Regional Health - Western Pacific
Volume22AbstractBackground: Contact-based intervention has been documented and proved effective on reducing stigma of mental illness in high-income countries, but it is still unclear about the effectiveness of the contact-based intervention among family caregivers of persons with schizophrenia (FCPWS) in low- and middle-income countries including rural China. Methods: We conducted a cluster randomized controlled trial in FCPWS in eight rural townships in Xinjin district of Chengdu city in Southwest China. The FCPWS in these townships were randomly allocated to the Enhancing Contact Model (ECM), Psychoeducational Family Intervention (PFI), or Treatment as Usual (TAU) group. FCPWS in three groups were provided specific interventions and follow-ups. By using a mixed-effect model, our goal was to examine the differences in affiliate self-stigma scale (ASSS) scores among three groups with the data collected at baseline (T0), post-intervention (T1), 3-month (T2), and 9-month (T3) follow-up timepoints, respectively. This trial is registered with ChiCTR, number ChiCTR2000039133. Findings: In April 2019, 253 FCPWS from 8 townships were randomly assigned to receive either ECM (cluster=3, n=90), PFI (cluster=2, n=81), or TAU (cluster=3, n=82). Compared with participants in the TAU group, participants in the ECM group had statistically significantly lower ASSS scores at 9-month follow-up (estimated parameter [EP]= -5.51, 95% CI -10.27 to -0.74, p=0.02). There were no statistically significantly different ASSS scores at 9-month follow up between ECM and PFI groups. Compared with participants in the PFI group, younger (<60 years old), with higher monthly income and other caregiver (e.g., parent, sibling, child) participants in the ECM group had statistically significantly lower ASSS scores in the 3-month follow-up (EP = -5.66, 95% CI -10.13 to -1.19, p<0.01; EP = -7.82, 95% CI -11.87 to -3.78, p<0.001; EP = -6.79, 95% CI -10.69 to -2.90, p<0.001, respectively). Interpretation: This first trial in rural China shows that ECM intervention, a new anti-stigma intervention model, is a promising method for reducing affiliate stigma among FCPWS. The ECM intervention is more effective and stable than the PFI on reducing affiliate stigma among FCPWS. Further research needs to explore whether a long-term intervention could produce a more positive anti-stigma outcome trajectory. Funding: General Research Fund, University Grants Committee, Hong Kong SAR (GRF, Grant No. 17605618, 2018-2021, PI: Dr. M.S. Ran).
Neurodegenerative model of schizophrenia: Growing evidence to support a revisit
Reducing public stigma toward individuals with psychosis across race and gender: A randomized controlled trial of young adultsAmsalem, D., Valeri, L., Jankowski, S. E., Yang, L. H., Bello, I., Nossel, I., Malinovsky, I., Smith, S., Ngo, H., Lieff, S. A., Pagdon, S., Lipp, A., Markowitz, J. C., Neria, Y., & Dixon, L. B.
Journal titleSchizophrenia Research
Page(s)195-202AbstractBackground: Social contact-based interventions effectively reduce stigma toward psychosis. We recently demonstrated the efficacy of a 90-second video intervention in reducing stigma. The current randomized controlled study presents four briefer videos differing in presenter's gender/race, with baseline, postintervention, and 30-day follow-up assessments. The study replicates previous findings and examine whether concordance of presenter's and viewer's race/gender enhanced the anti-stigma effect. Methods: Using a crowdsourcing platform, we recruited 1993 participants ages 18–35 years to one of four brief video-based interventions (Black/White female, Black/White male presenters) or a nonintervention control condition. In the videos, a young presenter with psychosis humanized their illness through an evocative description of living a meaningful and productive life. Results: Group-by-time ANOVA showed a significant group-by-time interaction for the total score of all five stigma domains: social distance, stereotyping, separateness, social restriction, and perceived recovery. One-way ANOVA showed greater reductions in video intervention groups than control at post-intervention and 30-day follow-up, but no differences between video groups. Matching race/gender did not further reduce stigma. Conclusions: This randomized controlled study replicated and extended previous research findings, by showing stigma reduction across videos that differ in the presenter's gender and race, thus enhancing generalizability. The videos described the experience of psychosis and reduced stigma, suggesting their potential utility on social media platforms to increase the likelihood of seeking services and ultimately may improve access to care among young individuals with psychosis. Future research should address intersectional stigma experiences by focusing on race/gender and culturally tailoring the narrative.
Stigma and coping experiences in Latinx individuals at clinical high-risk for psychosis
The stigma system: How sociopolitical domination, scapegoating, and stigma shape public healthFriedman, S. R., Williams, L. D., Guarino, H., Mateu-Gelabert, P., Krawczyk, N., Hamilton, L., Walters, S. M., Ezell, J. M., Khan, M., Di Iorio, J., Yang, L. H., & Earnshaw, V. A.
Journal titleJournal of Community Psychology
Page(s)385-408AbstractStigma is a fundamental driver of adverse health outcomes. Although stigma is often studied at the individual level to focus on how stigma influences the mental and physical health of the stigmatized, considerable research has shown that stigma is multilevel and structural. This paper proposes a theoretical approach that synthesizes the literature on stigma with the literature on scapegoating and divide-and-rule as strategies that the wealthy and powerful use to maintain their power and wealth; the literatures on racial, gender, and other subordination; the literature on ideology and organization in sociopolitical systems; and the literature on resistance and rebellion against stigma, oppression and other forms of subordination. we develop a model of the “stigma system” as a dialectic of interacting and conflicting structures and processes. Understanding this system can help public health reorient stigma interventions to address the sources of stigma as well as the individual problems that stigma creates. On a broader level, this model can help those opposing stigma and its effects to develop alliances and strategies with which to oppose stigma and the processes that create it.
Understanding Users’ Perspectives of Psychosocial Mechanisms Underpinning Peer Support Work in ChileLe, P. T. D., Agrest, M., Mascayano, F., Dev, S., Kankan, T., Dishy, G., Tapia-Muñoz, T., Tapia, E., Toso-Salman, J., Pratt, C., Alves-Nishioka, S., Schilling, S., Jorquera, M. J., Castro-Valdez, J., Geffner, N., Price, L. S. N., Conover, S., Valencia, E., Yang, L. H., Alvarado, R., & Susser, E. S.
Journal titleCommunity mental health journal
Page(s)111-120AbstractThis study explores the beliefs and attitudes about the psychosocial mechanisms of peer support work among users who participated in Critical Time Intervention-Task Shifting (CTI-TS), which tested the acceptability and feasibility of a peer support work model to improve community-based mental health care for individuals with psychosis in Latin America. We conducted a secondary analysis of 15 in-depth interviews with CTI-TS participants in Chile, using the framework method and defined the framework domains based on five major mechanisms of peer support work identified by a recent literature review. The analysis revealed that users’ perceptions of peer support work mechanisms were strongly shaped by personal motivations, beliefs about professional hierarchies, familial support, and the Chilean mental health system’s incipient recovery orientation. The findings underscore the importance of adopting culturally tailored strategies to promote peer support work, such as involving mental health professionals and fostering equal-powered relationships between PSWs and users.
Behavioral correlates of COVID-19 worry: Stigma, knowledge, and news sourceMeltzer, G. Y., Chang, V. W., Lieff, S. A., Grivel, M. M., Yang, L. H., & Des Jarlais, D. C.
Journal titleInternational journal of environmental research and public health
Issue21AbstractNon-adherence to COVID-19 guidelines may be attributable to low levels of worry. This study assessed whether endorsing COVID-19-stigmatizing restrictions, COVID-19 knowledge, and preferred news source were associated with being ‘very worried’ versus ‘not at all’ or ‘somewhat’ worried about contracting COVID-19. Survey data were collected in July–August 2020 from N = 547 New York State (NYS) and N = 504 national Amazon MTurk workers. Respondents who endorsed COVID-19 stigmatizing restrictions (NYS OR 1.96; 95% CI 1.31, 2.92; national OR 1.80; 95% CI 1.06, 3.08) and consumed commercial news (NYS OR 1.89; 95% CI 1.21, 2.96; national OR 1.93; 95% CI 1.24, 3.00) were more likely to be very worried. National respondents who consumed The New York Times (OR 1.52; 95% CI 1.00, 2.29) were more likely to be very worried, while those with little knowledge (OR 0.24; 95% CI 0.13, 0.43) were less likely to be very worried. NYS (OR 2.66; 95% CI 1.77, 4.00) and national (OR 3.17; 95% CI 1.95, 5.16) respondents with probable depression were also more likely to be very worried. These characteristics can help identify those requiring intervention to maximize perceived threat to COVID-19 and encourage uptake of protective behaviors while protecting psychological wellbeing.
Comparison of social cognition using an adapted Chinese version of the Reading the Mind in the Eyes Test in drug-naive and regularly medicated individuals with chronic schizophrenia and healthy controls in rural ChinaDeng, F., Phillips, M. R., Cai, B., Yu, G., Qian, M., Grivel, M. M., Chen, H., Ouyang, X., Xue, F., Zhao, M., Kegeles, L. S., Susser, E. S., Keshavan, M. S., Stone, W. S., & Yang, L. H.
Journal titlePsychological MedicineAbstractBackground Social cognition has not previously been assessed in treatment-naive patients with chronic schizophrenia, in patients over 60 years of age, or in patients with less than 5 years of schooling. Methods We revised a commonly used measure of social cognition, the Reading the Mind in the Eyes Test (RMET), by expanding the instructions, using both self-completion and interviewer-completion versions (for illiterate respondents), and classifying each test administration as 'successfully completed' or 'incomplete'. The revised instrument (RMET-CV-R) was administered to 233 treatment-naive patients with chronic schizophrenia (UT), 154 treated controls with chronic schizophrenia (TC), and 259 healthy controls (HC) from rural communities in China. Results In bivariate and multivariate analyses, successful completion rates and RMET-CV-R scores (percent correct judgments about emotion exhibited in 70 presented slides) were highest in HC, intermediate in TC, and lowest in UT (adjusted completion rates, 97.0, 72.4, and 49.9%, respectively; adjusted RMET-CV-R scores, 45.4, 38.5, and 34.6%, respectively; all p < 0.02). Stratified analyses by the method of administration (self-completed v. interviewer-completed) and by education and age ('educated-younger' v. 'undereducated-older') show the same relationship between groups (i.e. NC>TC>UT), though not all differences remain statistically significant. Conclusions We find poorer social cognition in treatment-naive than in treated patients with chronic schizophrenia. The discriminant validity of RMET-CV-R in undereducated, older patients demonstrates the feasibility of administering revised versions of RMET to patients who may otherwise be considered ineligible due to education or age by changing the method of test administration and carefully assessing respondents' ability to complete the task successfully.
Development of the Brief Educational Guide for Individuals in Need (BEGIN): A psychoeducation intervention for individuals at risk for psychosisHerrera, S. N., Lyallpuri, R., Sarac, C., Dobbs, M. F., Nnaji, O., Jespersen, R., DeLuca, J. S., Wyka, K. E., Yang, L. H., Corcoran, C. M., & Landa, Y.
Journal titleEarly Intervention in PsychiatryAbstractAim: Identification of individuals with psychosis risk (PR) through screening and specialized assessment is becoming more widespread in an effort to promote early intervention and improve recovery outcomes. PR individuals report interest in psychoeducation, though such interventions are currently lacking. Our goal was to develop a structured PR psychoeducation intervention grounded in theory and stakeholder feedback. Methods: By following a step-by-step intervention development model, we identified relevant conceptual frameworks, developed the content and format, and obtained stakeholder feedback. This process resulted in a 5-session PR psychoeducation intervention, Brief Educational Guide for Individuals in Need (BEGIN), with content conveyed visually via a slideshow presentation. PR individuals (n = 5) and parents of PR individuals (n = 5) reviewed BEGIN's content and format, and provided feedback through semi-structured qualitative interviews. Major themes were identified through iterative thematic analysis. Results: PR individuals and parents had a positive impression of BEGIN's materials and step-by-step format and psychoeducation about the PR condition. They indicated that the intervention was likely to encourage agency. PR participants emphasized the importance of a patient's decision regarding whether their family member(s) should participate in BEGIN. Parents reported that BEGIN is an important first step in treatment and offers a safe therapeutic environment. Feedback was then utilized to modify the intervention. Conclusions: BEGIN is desired by consumers and may lay the foundation for future engagement with treatment by facilitating agency. A feasibility trial is underway and future studies are needed to measure outcomes (e.g., treatment engagement) and evaluate BEGIN as an evidence-based PR psychoeducation model.
Disengagement from early intervention services for psychosis: A systematic review
Emotional and stigma-related experiences relative to being told one is at risk for psychosisWoodberry, K. A., Powers, K. S., Bryant, C., Downing, D., Verdi, M. B., Elacqua, K. M., Reuman, A. R., Kennedy, L., Shapiro, D. I., West, M. L., Huang, D., Crump, F. M., Grivel, M. M., Blasco, D., Herrera, S. N., Corcoran, C. M., Seidman, L. J., Link, B. G., McFarlane, W. R., & Yang, L. H.
Journal titleSchizophrenia Research
Page(s)44-51AbstractObjective: Despite the appeal of early intervention in psychosis, there is concern that identifying youth as having high psychosis risk (PR) may trigger stigma. This study employed a pre-post design to measure change in PR participants' emotions about PR upon being told of their PR status and according to whether this was the first time receiving this information. Methods: Participants (n = 54) identified as at PR via structured interview rated their emotions about PR before and after being told they were at PR. Qualitative analyses explored the valence of participant reflections on being given this information. Results: Participants reported significantly less negative emotion after being told of their PR status (p < .001), regardless of whether they were hearing this for the first time (p = .72). There was no change in positive emotions or the predominant belief that they should keep their PR status private. Most participants commented positively about the process of feedback but negatively about its impact on their self-perceptions and/or expectations of others' perceptions of them. Conclusion: This is the first study to collect pre-post data related to being told one is at PR and to examine quantitative and qualitative responses across and within individuals. For a majority of participants, clinical feedback stimulated negative stereotypes even as it relieved some distress. To actively address internalized stigma, clinicians providing feedback to PR youth must attend to the positive and negative impacts on how youth think about themselves as well as how they feel.
Identifying “What Matters Most” to Men in Botswana to Promote Resistance to HIV-Related StigmaMisra, S., Mehta, H. T., Eschliman, E. L., Rampa, S., Poku, O. B., Wang, W. Q., Ho-Foster, A. R., Mosepele, M., Becker, T. D., Entaile, P., Arscott-Mills, T., Opondo, P. R., Blank, M. B., & Yang, L. H.
Journal titleQualitative Health Research
Page(s)1680-1696AbstractDespite a comprehensive national program of free HIV services, men living with HIV in Botswana participate at lower rates and have worse outcomes than women. Directed content analysis of five focus groups (n = 38) and 50 in-depth interviews with men and women with known and unknown HIV status in Gaborone, Botswana in 2017 used the “what matters most” (WMM) and “structural vulnerability” frameworks to examine how the most valued cultural aspects of manhood interact with HIV-related stigma. WMM for manhood in Botswana included fulfilling male responsibilities by being a capable provider and maintaining social status. Being identified with HIV threatened WMM, which fear of employment discrimination could further exacerbate. Our findings indicate how cultural and structural forces interact to worsen or mitigate HIV-related stigma for urban men in Botswana. These threats to manhood deter HIV testing and treatment, but interventions could capitalize on cultural capabilities for manhood to promote stigma resistance.
Naturalistic conceptions of genetic optimism and precision psychiatry among those at clinical high-risk for psychosisBlasco, D., Stortz, S. W., Grivel, M. M. R., Dishy, G. A., Samuel, S. S., Pilla, D., Crump, F. M., Lieff, S. A., Williams, J., Phoummavong, P., Guo, X., Brucato, G., Girgis, R. R., & Yang, L. H.
Journal titleEarly Intervention in Psychiatry
Page(s)742-745AbstractAim: Fuelled by genomics advances, recent emphasis on the concept of “precision medicine,” and public optimism towards genetic advances, it is important to understand how those who are considered to be at clinical high-risk for psychosis (CHR) perceive possible benefits of genetic testing to inform future stakeholder education efforts. Methods: Semistructured interviews were completed with 20 participants who met CHR criteria. Coding for genetic optimism was completed. Results: Participants endorsed many conceptualizations of the link between genetics, the development of psychosis, and the benefits of genetic testing. Specifically, themes emerged surrounding how genetic testing may lead to greater genetic knowledge and tailored treatment. Conclusions: Our results demonstrate that CHR participants generally endorse several precision psychiatry concepts, including how genetic testing may lead to tailored treatment advances. This knowledge may aid development of best communication practices regarding forthcoming genetic advances in diagnosis and treatment among CHR.
Peer-to-peer contact, social support and self-stigma among people with severe mental illness in Hong KongLi, X. H., Zhang, T. M., Yau, Y. Y., Wang, Y. Z., Wong, Y. L. I., Yang, L., Tian, X. L., Chan, C. L. W., & Ran, M. S.
Journal titleInternational Journal of Social Psychiatry
Page(s)622-631AbstractBackground: Self-stigma exerts a range of adversities for persons with severe mental illness (SMI), however, little is known about the association between peer contact, social support and self-stigma. Aims: This study aimed to explore the mediating role of social support on the relationship between peer contact and self-stigma among persons with SMI in Hong Kong. Methods: A total of 159 persons with SMI (schizophrenia and mood disorder) in community service centres participated in the study through completing a survey on self-stigma, social functioning, social support, perception of peer contact and mass media. Logistic regression was utilised to explore the influencing factors of self-stigma among the participants. Results: The results showed that 81.1% of participants reported moderate to severe levels of self-stigma. Self-stigma was significantly associated with diverse factors (e.g. social functioning). Importantly, positive peer contact was significantly associated with lower self-stigma of persons with SMI. Social support acted as a mediator between peer contact and self-stigma. Conclusion: The results of this study suggest that contact-based interventions, such as enhancing positive peer-to-peer contact, should be conducted for reducing self-stigma among persons with SMI.
Psychometric Validation of a Scale to Assess Culturally-Salient Aspects of HIV Stigma Among Women Living with HIV in Botswana: Engaging “What Matters Most” to Resist Stigma
Reducing Stigma among Youth at Risk for Psychosis: A Call to ActionDeluca, J. S., Yang, L. H., Lucksted, A. A., Yanos, P. T., Devylder, J., Anglin, D. M., Landa, Y., & Corcoran, C. M.
Journal titleSchizophrenia bulletin
Reducing Stigma Toward Individuals With Schizophrenia Using a Brief Video: A Randomized Controlled Trial of Young AdultsAmsalem, D., Yang, L. H., Jankowski, S., Lieff, S. A., Markowitz, J. C., & Dixon, L. B.
Journal titleSchizophrenia bulletin
Page(s)7-14AbstractOBJECTIVE: Stigma decreases healthcare seeking and treatment adherence and increases the duration of untreated psychosis among people with first-episode psychosis (FEP). This study evaluated the efficacy of a brief video-based intervention in reducing stigma among youth toward individuals with FEP and schizophrenia. We hypothesized that the social-contact-based video intervention group would reduce stigma more than written vignette and control groups, and the vignette more than the control group. METHODS: Using Amazon Mechanical Turk, we recruited and assigned 1203 individuals aged 18-30 to either (a) video intervention, (b) written description of the same content ("vignette"), or (c) nonintervention control arm. In the 90-second video intervention, an empowered young woman with schizophrenia described her FEP and the aspects of successful coping with her everyday life difficulties, exposing the viewer to schizophrenia in the context of her personal narrative. Web-based self-report questionnaires assessed stigma domains, including social distance, stereotyping, separateness, social restriction, and perceived recovery. RESULTS: A MANOVA showed a significant between-group effects for all 5 stigma-related subscales (P < .001). Post hoc pairwise tests showed significant differences between video and vignette vs control for all 5 stigma domains. Video and vignette groups differed significantly on social distance, stereotyping, and social restriction. Secondary analyses revealed gender differences across stigma domains in the video group only, with women reporting lower stigma. CONCLUSIONS: A very brief social contact-based video intervention efficaciously reduced stigma toward individuals with FEP. This is the first study to demonstrate such an effect. Further research should examine its long-term sustainability.
Sociodemographic and Behavioral Factors Associated With COVID-19 Stigmatizing Attitudes in the U.S.Grivel, M. M., Lieff, S. A., Meltzer, G. Y., Chang, V. W., Yang, L. H., & Jarlais, D. C.
Journal titleStigma and Health
Page(s)371-379AbstractTo control the spread of coronavirus disease (COVID-19) and prevent further verbal and physical discrimination against individuals affected by, or perceived to be responsible for, COVID-19, proactive efforts must be made to ameliorate stigmatizing attitudes. This study seeks to examine whether key sociobehavioral factors including news consumption and contact with Chinese individuals are associated with COVID-19 stigma as a first step to informing stigma interventions. Surveys were administered to N = 498non-representative national respondents in August 2020 via Amazon’s Mechanical Turk and includedassessments of COVID-19 stigma, worry, knowledge, contact with COVID-19 and Chinese individuals, and preferred news source. Prevalence of stigmatizing beliefs was 65.46%. Odds of endorsing stigma were higher among males (OR = 1.77, 95% CI [1.07–2.93]) vs. females, Non-Hispanic Black (OR = 3.12, 95% CI [1.42–6.86]) and Hispanic (OR = 4.77, 95% CI [2.32–9.78]) vs. Non-Hispanic White individuals, and individuals with college degrees (OR = 3.41, 95% CI [1.94–5.99]) and more than college degrees (OR = 3.04, 95% CI [1.34–6.89]) vs. those with less than college degrees. Consumers (vs. non-consumers) of Fox News (OR = 4.43, 95% CI [2.52–7.80]) and social media (OR = 2.48, 95% CI [1.46–4.20]) had higher odds of endorsing stigma. Contact with Chinese individuals (OR = 0.50, 95% CI [0.25–1.00]) wasassociated with lower odds of endorsing stigma. These findings suggest that individuals of Non-HispanicBlack or Hispanic race/ethnic background, consumers of Fox News and social media, men, and individuals with college degrees or higher are groups that should be prioritized for anti-stigma intervention. Our finding that social contact with Chinese individuals is associated with decreased odds of stigma that provides initial support for the implementation of interventions based on contact with individuals of Chinese descent
Stigma of Treatment Stages for First-Episode Psychosis: A Conceptual Framework for Early Intervention ServicesYang, L. H., Blasco, D., Lieff, S. A., Le, P. T. D., Li, Y. P., Broeker, M., Mascayano, F., Bello, I., Nossel, I., & Dixon, L.
Journal titleHarvard Review of Psychiatry
Page(s)131-141AbstractABSTRACT: Early intervention services (EIS; in the United States, Coordinated Specialty Care) can lead to substantial improvements in psychiatric symptoms and social functioning for individuals with first-episode psychosis who engage in treatment. Nevertheless, stigma associated with early intervention services can limit their full potential benefits by preventing or reducing participation. Drawing from Corrigan's "why try" model positing relationships between public and self-stigma, engagement in treatment services, and the EIS treatment model, this article proposes a framework that delineates how distinct forms of stigma are linked to given stages of treatment engagement in first-episode psychosis. We identify three phases of engagement: (1) community outreach, which has associations with public stigma; (2) the referral and evaluation process, which primarily has associations with self-stigma; and (3) EIS, which have associations with self-stigma and its psychosocial consequences. For each phase, we describe evidence-based strategies typically provided by EIS programs, using OnTrackNY as an exemplary model, to illustrate potential linkages in our conceptual framework. By specifying how distinct forms of stigma are associated with EIS treatment stages, this framework is intended to guide EIS programs in explicitly addressing stigma to optimize recovery of individuals with first-episode psychosis.
Stigma, Structural Vulnerability, and "What Matters Most" Among Women Living With HIV in Botswana, 2017Yang, L. H., Poku, O. B., Misra, S., Mehta, H. T., Rampa, S., Eisenberg, M. M., Yang, L. S., Dai Cao, T. X., Blank, L. I., Becker, T. D., Link, B. G., Entaile, P., Opondo, P. R., Arscott-Mills, T., Ho-Foster, A. R., & Blank, M. B.
Journal titleAmerican journal of public health
Page(s)1309-1317AbstractObjectives. To explore whether beneficial health care policies, when implemented in the context of gender inequality, yield unintended structural consequences that stigmatize and ostracize women with HIV from "what matters most" in local culture. Methods. We conducted 46 in-depth interviews and 5 focus groups (38 individuals) with men and women living with and without HIV in Gaborone, Botswana, in 2017. Results. Cultural imperatives to bear children bring pregnant women into contact with free antenatal services including routine HIV testing, where their HIV status is discovered before their male partners'. National HIV policies have therefore unintentionally reinforced disadvantage among women with HIV, whereby men delay or avoid testing by using their partner's status as a proxy for their own, thus facilitating blame toward women diagnosed with HIV. Gossip then defines these women as "promiscuous" and as violating the essence of womanhood. We identified cultural and structural ways to resist stigma for these women. Conclusions. Necessary HIV testing during antenatal care has inadvertently perpetuated a structural vulnerability that propagates stigma toward women. Individual- and structural-level interventions can address stigma unintentionally reinforced by health care policies.
Sustained Effect of a Brief Video in Reducing Public Stigma Toward Individuals With Psychosis: A Randomized Controlled Trial of Young AdultsAmsalem, D., Markowitz, J. C., Jankowski, S. E., Yang, L. H., Valeri, L., Lieff, S. A., Neria, Y., & Dixon, L. B.
Journal titleThe American journal of psychiatry
Page(s)635-642AbstractOBJECTIVE: Public stigma is a barrier to care and increases the duration of untreated psychosis among individuals with first-episode psychosis. The authors recently demonstrated the efficacy of a 90-second social contact-based video intervention in reducing such stigma. That proof-of-concept study was the first to employ so brief an antistigma intervention in a sample of young adults. The authors now present a randomized controlled replication study with baseline, postintervention, and 30-day follow-up assessments. The authors aimed to replicate their previous findings and to show a persisting benefit for the video intervention. METHODS: Using a crowdsourcing platform (Amazon Mechanical Turk), the authors recruited and assigned 1,055 participants ages 18-30 years to a brief video-based intervention, to a written vignette intervention containing the same material, or to a nonintervention control condition. In the 90-second video, a 22-year-old African American woman with schizophrenia humanized the illness through her emotional description of living a meaningful and productive life. RESULTS: A three-by-three group-by-time multivariate analysis of variance showed a significant group-by-time interaction for the total scores of all five stigma-related domains: social distance, stereotyping, separateness, social restriction, and perceived recovery. Post hoc pairwise tests showed greater reductions in the video group compared with the vignette and control groups at the postintervention and 30-day follow-up assessments, while the vignette group differed from the control group at the postintervention assessment but not at the 30-day assessment. CONCLUSIONS: This randomized controlled study replicated and strengthened the authors' earlier findings, further showing month-long sustained stigma reduction in the social contact-based video intervention arm. A 90-second video sufficed to humanize schizophrenia and reduce stigma. Further research should examine longer-term sustainability, assess changes in behavior, and determine optimal effective video length.
Systematic Review of Cultural Aspects of Stigma and Mental Illness among Racial and Ethnic Minority Groups in the United States: Implications for InterventionsMisra, S., Jackson, V. W., Chong, J., Choe, K., Tay, C., Wong, J., & Yang, L. H.
Journal titleAmerican journal of community psychology
Page(s)486-512AbstractStigma is integral to understanding mental health disparities among racial and ethnic minority groups in the United States. We conducted a systematic review to identify empirical studies on cultural aspects of mental illness stigma (public, structural, affiliative, self) among three racial and ethnic minority groups (Asian Americans, Black Americans, Latinx Americans) from 1990 to 2019, yielding 97 articles. In comparison studies (N = 25), racial and ethnic minority groups often expressed greater public and/or self-stigma than White American groups. In within-group studies (N = 65; Asian American, n = 21; Black American, n = 18; Latinx American; n = 26), which were primarily qualitative (73%), four major cultural themes emerged: 1) service barriers including access and quality (structural stigma); 2) family experiences including concealment for family’s sake, fear of being a burden, and stigma extending to family (affiliative stigma); 3) lack of knowledge about mental illness and specific cultural beliefs (public stigma); and 4) negative emotional responses and coping (self-stigma). These findings confirmed stigma has both similar and unique cultural aspects across groups. Despite this, few studies tested stigma reduction interventions (N = 7). These cultural insights can inform contextual change at the health systems and community levels to reduce stigma, and empowerment at the interpersonal and individual levels to resist stigma.