Lawrence H Yang
Associate Professor of Social and Behavioral Sciences
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 cross-culturally to improve the lives of countless people with mental illness and their families around the world.
"I was drawn by the global and applied perspective of GPH. I saw working at GPH as an incredible research opportunity to build mental health programs and the school's ties to NYU Shanghai as a unique opportunity to further establish research studies throughout China," said Larry regarding his new position on the GPH Social and Behavioral Sciences team. As part of the faculty, Larry will teach Psychometric Measurement and Analysis in the fall as well as a Social Behavioral Sciences course in the spring. In addition to teaching, Larry will continue several ongoing research studies on the forefront of public health and psychiatric epidemiology.
As PI of a five year study, R01-Stigma of Clinical High-Risk Psychosis (CHR) funded by the NIMH, Larry is examining the impact of stigma on identity among youth diagnosed with a Clinical High-Risk State for Psychosis (CHR). The research is being conducted in partnership with the medical schools of Harvard, Columbia and Maine. "People used to think that intervening with psychosis when a person first has a psychotic break was early intervention," said Larry. "Now, we understand that the first psychotic break is actually well into the development of the disorder." Using a diagnostic interview that identifies a Clinical High-Risk Psychosis state to look for clinical features and symptoms of psychosis, a mental health professional can detect the signs of psychosis and begin treatment. Early treatment can help delay onset of psychosis and possibly improve the course of the illness. Yet, only 30 percent of those with the earliest signs of psychosis will develop a full-psychotic disorder. "Early detection comes with a potential cost," said Larry. "There are all sorts of implications regarding how early diagnosis could negatively affect a young person's identity and the way the rest of the world views them." For the past four years, Larry has been examining the impact of psychological, social, and developmental outcomes among participants identified as CHR. The study is now in its 5th year and nearing completion. Additionally, Larry is conducting a supplemental study to examine the manifestation of stigma using neuroimaging and to determine whether and how stigma is expressed in the brain.
Larry's fascination with stigma was first sparked during his dissertation research in Shanghai 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 severe mental health in Shanghai. "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. You have no way to access the common things that most people do in their everyday lives. People call this being 'faceless' or 'social death'." From this experience, Larry became motivated to do something to empower people with mental illness and their families within their communities.
After receiving an NIMH K-award, Larry conducted a study in New York City of the psychological factors, including stigma, that shape the course of mental illness among Chinese immigrants. As a result of this study, Larry formulated theoretical work on how culture relates to stigma and implementing interventions to improve recovery for different stigmatizing conditions on which his future research is based. He learned that upholding face (or preserving honor and the community's respect) 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. Resulting from his K-Award, Larry used the study to formulate an anti-stigma intervention to help people with mental illness take a powerful step towards regaining face. "Arthur Kleinman and I call it "remobilization", Larry said. "We helped Chinese immigrants with psychosis move from a position where they were completely disempowered in society to a place where they could reengage with society. To work if they wish, to volunteer if they wish. We were able to help them re-engage in social interaction and reduce internalized stigma." Although his anti-stigma intervention has been based in the US, they have now conducted similar research in China and in other international settings such as Chile, Argentina, India and Botswana.
Larry returned to China as PI of an R01 study with co-PI's, Michael Phillips and Larry Seidman, Characterizing Cognition of Untreated Psychosis in China. Recently, China has been rolling out programs in detection of untreated psychosis around the country. As the program had not yet reached the poorest provinces in China, including Ningxia, Larry chose to propose a study there which has since become supported by the Ningxia Ministry of Health. The study includes 400 untreated psychosis participants, who are then matched with 400 treated psychosis participants and an additional 400 healthy control participants in Ningxia Province.
"If you've ever seen "A Beautiful Mind", you may have noted that there were points where the main character John Nash, Jr. maintained his brilliance and others where he was more dull and slowed down. Unfortunately, this slowing of cognition happens to a lot of people with psychosis. But we've never been able to disentangle how much of this is connected to the illness and how much is due to the medication. This study is a historic scientific opportunity to examine what cognition looks like in people who are completely untreated for psychosis."
Additionally, Larry's team will work with Michael Phillips and local psychiatrists in the province to scale up their capacity to treat first episode psychosis by providing more advanced clinical training.
While Larry has conducted several studies in China, his latest research has also taken him to South America (Argentina, Chile and Brazil). Currently, he is part of a study, the Collaborative Hub for International Research in Mental Health, an NIMH U-19, establishing a network of research hubs: two in South America (including his team's study in Chile, Argentina and Brazil), one in Asia and one in Africa. Following a scale up intervention conducted by his research partners, Larry co-leads a qualitative evaluation to measure the barriers and facilitators to scale-up social interventions for psychosis in Latin America and across all hub sites. His collaborating research partners on this study include the University of Chile (Santiago) and the University of Frederico (Rio). Larry's role is to harmonize interviews and the collection of data across all five global hub sites so that the research teams can collect uniform data to facilitate the scale up of interventions worldwide.
Larry holds a doctoral degree from Boston University in Clinical Psychology. He was awarded a clinical fellowship at Harvard Medical School to work at the Massachusetts Mental Health Center and has received 8 early career awards for his work on stigma, 6 of which are national. Larry is a member of two prestigious editorial boards: the Cultural Diversity and Ethnic Minority Psychology Board of the Journal of the American Psychological Association, and the Stigma and Health Board of the Journal of the American Psychological Association. He has also authored publications in The Lancet, British Journal of Psychiatry, and the Journal of Abnormal Psychology.
BA, High Honors and Phi Beta Kappa, Wesleyan University, Middletown, CTPhD, Boston University, Boston, MAClinical Fellowship, Harvard Medical School-Massachusetts Mental Health Center
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)
Community HealthCultural Determinants of HealthEpidemiologyImmigrationMental HealthMinoritiesMinority HealthPsychologyStigma
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.
Disengagement from early intervention services for psychosis: A systematic reviewMascayano, F., Van Der Ven, E., Martinez-Ales, G., Henao, A. R., Zambrano, J., Jones, N., Cabassa, L. J., Smith, T. E., Yang, L. H., Susser, E., & Dixon, L. B.
Journal titlePsychiatric Services
Page(s)49-60AbstractObjective: Therapeutic benefits associated with early services for psychosis are influenced by the degree to which participants engage in treatment. The main objective of this review was to analyze rates of disengagement in early psychosis services and identify predictors of disengagement in these settings. Methods: A systematic search for studies published in the 1966-2019 period was conducted in PubMed, Google Scholar, EBSCO, Ovid, and Embase. The Observational Cohort and Cross-Sectional Studies scale was used to assess the methodological quality of reports identified in this search. A revised version of the behavioral model of health service use was employed to evaluate and understand predictors of disengagement (categorized as predisposing, enabling, and need factors) identified in the studies with the highest quality. Results: Twenty studies met the inclusion criteria. Disengagement rates (12% to 53%) and definitions of disengagement varied widely across these studies. Most did not find a compelling association between predisposing factors (e.g., age) and disengagement. Enabling factors, such as lack of family support and living alone, were consistently found to be related to increased disengagement across studies. Finally, need factors, such as lower medication adherence and higher drug misuse, were associated with higher risk for disengagement. Conclusions: Enabling and need factors seemed to be the most predictive of disengagement from early psychosis services. Substantial between-study variation in identified predictors of disengagement may be addressed by developing and applying a consensus definition of disengagement in future research.
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.
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 StigmaYang, L. H., Ho-Foster, A. R., Becker, T. D., Misra, S., Rampa, S., Poku, O. B., Entaile, P., Goodman, M., & Blank, M. B.
Journal titleAIDS and Behavior
Page(s)459-474AbstractPerceived stigma deters engagement in HIV care and is powerfully shaped by culture. Yet few stigma measures consider how cultural capabilities that signify “full personhood” could be engaged to resist stigma. By applying a theory conceptualizing how culturally-salient mechanisms can worsen or mitigate HIV stigma in relation to “what matters most” (WMM), we developed the WMM Cultural Stigma Scale for Women Living with HIV in Botswana (WMM-WLHIV-BW) and psychometrically evaluated it among 201 respondents with known and unknown HIV status. The two subscales, Cultural Factors Shape Stigma (CFSS) and Cultural Capabilities Protect against Stigma (CCPS) were reliable (both α= 0.90). Among WLHIV, the CFSS Subscale showed initial construct validity with depressive symptoms (r =.39, p =.005), similar to an established HIV stigma scale, whereas the CCPS Subscale showed initial construct validity with self-esteem (r =.32, p =.026) and social support number (r =.29, p =.047), suggesting that achieving local cultural capabilities mitigates stigma and is linked with positive psychosocial outcomes. This culturally-derived scale could help WLHIV in Botswana experience improved stigma-related outcomes.
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.
Stigma and coping experiences in Latinx individuals at clinical high-risk for psychosisRuiz, B., Ceccolini, C. J., Shah, B. B., Crump, F., Girgis, R. R., Brucato, G., Yang, L. H., & Corcoran, C. M.
Journal titleEarly Intervention in PsychiatryAbstractAim: The experiences of culturally diverse individuals at clinical high-risk for psychosis (CHR) is not well studied. Exploratory research needs to examine whether differences exist between racial/ethnic groups within the CHR population. Understanding experiences of Latinx patients is of importance, as the Latinx population represents the most rapidly growing paediatric population in the United States and they face significant barriers to mental health treatment. Because Latinx persons experience high rates of mental illness-based stigma and discrimination in their communities, they may face additional stigma-based barriers to CHR treatment. Method: Twenty-six participants (15 Latinx, 11 non-Latinx white/NLW) who met CHR criteria based on the Structured Interview for Psychosis-Risk Syndromes (SIPS) were interviewed regarding stigma associated with CHR identification and symptoms. Using a consensus-based open-coding thematic analysis approach, data were analysed for stigma, discrimination, and coping responses. Results: Instances of internalization of stereotypes appeared to be more salient to NLW participants than Latinx participants, and Latinx participants reported seemingly more anticipated rejection from stereotypes than NLW participants. Experiences of discrimination also appeared to be more salient to Latinx participants than NLW participants. Moreover, Latinx participants reported evidently greater instances of discrimination across anticipated, individual, and structural discrimination. Finally, while covering strategies appeared to be more salient to NLW's, Latinx clients more often described using secrecy as well as a greater range of coping responses, including empowerment. Conclusion: While the experience of anticipated rejection appeared to be more salient to Latinx CHR participants and they seemingly report more secrecy than NLW, they also engaged in empowerment-related coping strategies. Future research should continue to explore the roles of cultural values in influencing coping strategies among CHR individuals.
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.
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 psychologyAbstractStigma 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.
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 PsychologyAbstractStigma 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 journalAbstractThis 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.
A Narrative Review of Alzheimer's Disease StigmaRosin, E. R., Blasco, D., Pilozzi, A. R., Yang, L. H., & Huang, X.
Journal titleJournal of Alzheimer's Disease
Page(s)515-528AbstractAs the most common form of senile dementia, Alzheimer's disease (AD) is accompanied by a great deal of uncertainty which can lead to fear and stigma for those identified with this devastating disease. As the AD definition evolves from a syndromal to a biological construct, and early diagnoses becomes more commonplace, more confusion and stigma may result. We conducted a narrative review of the literature on AD stigma to consolidate information on this body of research. From the perspective of several stigma theories, we identified relevant studies to inform our understanding of the way in which implementation of the new framework for a biological based AD diagnosis may have resulted in new and emerging stigma. Herein, we discuss the emergence of new AD stigma as our understanding of the definition of the disease changes. We further propose recommendations for future research to reduce the stigma associated with AD.
Advancing study of cognitive impairments for antipsychotic-naïve psychosis comparing high-income versus low- and middle-income countries with a focus on urban China: Systematic review of cognition and study methodologyYang, L. H., Ruiz, B., Mandavia, A. D., Grivel, M. M., Wong, L. Y., Phillips, M. R., Keshavan, M. S., Li, H., Lieberman, J. A., Susser, E., Seidman, L. J., & Stone, W. S.
Journal titleSchizophrenia Research
Page(s)1-15AbstractBackground: Comparing the course of antipsychotic-naïve psychosis in low- and middle-income countries (LMIC) may help to illuminate core pathophysiologies associated with this condition. Previous reviews-primarily from high-income countries (HIC)-identified cognitive deficits in antipsychotic-naïve, first-episode psychosis, but did not examine whether individuals with psychosis with longer duration of untreated psychosis (DUP > 5 years) were included, nor whether LMIC were broadly represented. Method: A comprehensive search of PUBMED from January 2002-August 2018 identified 36 studies that compared cognitive functioning in antipsychotic-naïve individuals with psychosis (IWP) and healthy controls, 20 from HIC and 16 from LMIC. Results: A key gap was identified in that LMIC study samples were primarily shorter DUP (<5 years) and were primarily conducted in urban China. Most studies matched cases and controls for age and gender but only 9 (24%) had sufficient statistical power for cognitive comparisons. Compared with healthy controls, performance of antipsychotic-naïve IWP was significantly worse in 81.3% (230/283) of different tests of cognitive domains assessed (90.1% in LMIC [118/131] and 73.7% [112/152] in HIC). Conclusions: Most LMIC studies of cognition in antipsychotic-naïve IWP adopted standardized procedures and, like HIC studies, found broad-based impairments in cognitive functioning. However, these LMIC studies were often underpowered and primarily included samples typical of HIC: primarily male, young-adult, high-school educated IWP, in their first episode of illness with relatively short DUP (<5 years). To enhance understanding of the long-term natural course of cognitive impairments in untreated psychosis, future studies from LMIC should recruit community-dwelling IWP from rural areas where DUP may be longer.
Association between the Duration of Untreated Psychosis and Selective Cognitive Performance in Community-Dwelling Individuals with Chronic Untreated Schizophrenia in Rural ChinaPhillips, M. R., Stone, W. S., Cai, B., Liu, X., Grivel, M. M., Yu, G., Xu, Y., Ouyang, X., Chen, H., Deng, F., Xue, F., Li, H., Lieberman, J. A., Keshavan, M. S., Susser, E. S., & Yang, L. H.
Journal titleJAMA Psychiatry
Page(s)1116-1126AbstractImportance: Cognitive deficits constitute core features of schizophrenia, but the trajectories of cognitive difficulties in chronic untreated schizophrenia remain unclear. Objective: To assess the association of neuropsychological deficits with duration of untreated psychosis in individuals with chronic untreated schizophrenia. Design, Setting, and Participants: Community-dwelling individuals with chronic untreated schizophrenia (untreated patient group) and individuals without mental illness (control group) were recruited from predominantly rural communities in Ningxia, China between June 20, 2016, and August 6, 2019, and administered the Structured Clinical Interview for DSM-IV, the Mini-Mental State Examination, an 8-test version of the MATRICS Consensus Cognition Battery adapted for use in individuals with low levels of education, and a measure of social cognition. Main Outcomes and Measures: Comparison of cognitive test scores between the two groups and association of cognitive test scores with duration of untreated schizophrenia. Results: The patient group included 197 individuals with chronic untreated schizophrenia (101 men [51.3%]; mean [SD] age, 52.1 [11.8] years; median [interquartile range] years of schooling, 3 [0-6] years; median [interquartile range] years of untreated psychosis, 22.9 [14.9-32.8] years). The control group included 220 individuals (118 men [53.6%]; mean [SD] age, 52.1 [11.2] years; median [interquartile range] years of schooling, 4 [0-6] years). The untreated patient group performed significantly worse than the control group on all cognitive measures (adjusted partial Spearman correlation coefficient [Spearman ρ] ranged from-0.35 for the revised Chinese version of the Reading the Mind in the Eyes Test to-0.60 for the Brief Visuospatial Memory Test-Revised; P <.001 for all comparisons). Longer durations of untreated psychosis were associated with lower performance in 3 MATRICS Consensus Cognition Battery measures assessing different aspects of executive functioning (Brief Visuospatial Memory Test-Revised [ρ =-0.20; P =.04]; Brief Assessment of Cognition in Schizophrenia, Symbol Coding subtest [ρ =-0.35; P <.001]; and Neuropsychological Assessment Battery, Mazes subtest [ρ =-0.24; P =.01]). The median duration of untreated psychosis (22.9 years) was associated with estimated score reductions in the 3 measures of 34% (95% CI, 10%-52%), 43% (95% CI, 28%-55%), and 57% (95% CI, 31%-73%), respectively. Conclusions and Relevance: The findings of this study suggest that long-term untreated schizophrenia was associated with decreases in selective cognitive abilities; both neurodegenerative pathology and neurodevelopmental dysfunction may be factors in cognition in persistent psychosis. Expanding research to include cohorts of patients from underserved rural communities in low- A nd middle-income countries may provide new insights about the etiological factors, disease course, and management of schizophrenia.
Botswana's HIV response: Policies, context, and future directionsRamogola-Masire, D., Poku, O., Mazhani, L., Ndwapi, N., Misra, S., Arscott-Mills, T., Blank, L., Ho-Foster, A., Becker, T. D., & Yang, L.
Journal titleJournal of Community Psychology
Page(s)1066-1070AbstractThis brief report describes key periods in the history of the national public health response to the human immunodeficiency virus (HIV) epidemic in Botswana. It reveals the context leading to the development of HIV policies presently in place and current challenges that remain. The report concludes with opportunities for future directions, initiatives, and policy changes to reduce the high rates of HIV.
HIV and Depression: Examining Medical Students Clinical SkillsRivera-Segarra, E., Carminelli-Corretjer, P., Varas-Díaz, N., Neilands, T. B., Yang, L. H., & Bernal, G.
Journal titleFrontiers in Psychiatry
Volume11AbstractMajor depression is a prevalent psychiatric disorder among people living with HIV (PWH). Major depression symptoms, including suicidal ideation, can hinder clinical care engagement and anti-retroviral treatment adherence. Research suggests that inquiry about major depression symptomatology and suicidal ideation should be standard practice when offering primary care services to PWH. However, studies examining depression and suicidal ideation inquiry are scarce. This study’s aim was to describe medical students’ clinical skills for dealing with major depression symptomatology and suicidal ideation among PWH in Puerto Rico. A total of 100 4th year medical students participated in a Standardized Patient simulation with a trained actor posing as a PWH and with a previous major depression diagnosis. One-way frequency tables were used to characterize the sample and the percentage of each observed clinical skill. Two key findings stem from these results only 10% of the participants referred the patient to psychological/psychiatric treatment, and only 32% inquired about suicidal ideation. Our findings highlight the need for enhancing medical students’ competencies regarding mental health issues, particularly when providing services to at risk populations such as PWH within primary care settings.
Including culture in programs to reduce stigma toward people with mental disorders in low- and middle-income countriesMascayano, F., Toso-Salman, J., Ho, Y. C. S., Dev, S., Tapia, T., Thornicroft, G., Cabassa, L. J., Khenti, A., Sapag, J., Bobbili, S. J., Alvarado, R., Yang, L. H., & Susser, E.
Journal titletranscultural psychiatry
Page(s)140-160AbstractStigma is one of the main barriers for the full implementation of mental health services in low- and middle-income countries (LMICs). Recently, many initiatives to reduce stigma have been launched in these settings. Nevertheless, the extent to which these interventions are effective and culturally sensitive remains largely unknown. The present review addresses these two issues by conducting a comprehensive evaluation of interventions to reduce stigma toward mental illness that have been implemented in LMICs. We conducted a scoping review of scientific papers in the following databases: PubMed, Google Scholar, EBSCO, OVID, Embase, and SciELO. Keywords in English, Spanish, and Portuguese were included. Articles published from January 1990 to December 2017 were incorporated into this article. Overall, the studies were of low-to-medium methodological quality—most only included evaluations after intervention or short follow-up periods (1–3 months). The majority of programs focused on improving knowledge and attitudes through the education of healthcare professionals, community members, or consumers. Only 20% (5/25) of the interventions considered cultural values, meanings, and practices. This gap is discussed in the light of evidence from cultural studies conducted in both low and high income countries. Considering the methodological shortcomings and the absence of cultural adaptation, future efforts should consider better research designs, with longer follow-up periods, and more suitable strategies to incorporate relevant cultural features of each community.
Mothers moving towards empowerment' intervention to reduce stigma and improve treatment adherence in pregnant women living with HIV in Botswana: Study protocol for a pragmatic clinical trialPoku, O. B., Ho-Foster, A. R., Entaile, P., Misra, S., Mehta, H., Rampa, S., Goodman, M., Arscott-Mills, T., Eschliman, E., Jackson, V., Melese, T., Becker, T. D., Eisenberg, M., Link, B., Go, V., Opondo, P. R., Blank, M. B., & Yang, L. H.
Issue1AbstractBackground: With high rates of HIV and multiple vulnerable subgroups across diverse settings, there is a need for culturally based, HIV stigma reduction interventions. Pregnant women who are living with HIV are especially in need of services to protect not only their own but also their children's lives. Uptake of HIV services worldwide is hindered by stigma towards persons living with HIV/AIDS. While cultural context plays a key role in shaping HIV stigma, these insights have not yet been fully integrated into stigma reduction strategies. By utilizing the "What Matters Most"stigma framework, we propose that an intervention to counter culturally salient aspects of HIV stigma will improve treatment adherence and other relevant outcomes. A pragmatic clinical trial in Botswana will evaluate the "Mothers Moving towards Empowerment"(MME) intervention, which seeks to address HIV stigma in Botswana and to specifically engage pregnant mothers so as to promote antiretroviral therapy (ART) adherence in the postpartum period. Methods: This study will test MME against treatment as usual (TAU) among pregnant mothers diagnosed with HIV and their infants. Outcomes will be assessed during pregnancy and 16 weeks postpartum. Women who meet eligibility criteria are assigned to MME or TAU. Women assigned to MME are grouped with others with similar estimated delivery dates, completing up to eight intervention group sessions scheduled before week 36 of their pregnancies. Primary outcomes among mothers include (i) reducing self-stigma, which is hypothesized to mediate improvements in (ii) psychological outcomes (quality of life, depression and social functioning), and (iii) adherence to antenatal care and ART. We will also examine a set of follow-up infant birth outcomes (APGAR score, preterm delivery, mortality (at < 16 weeks), birth weight, vaccination record, and HIV status). Discussion: Our trial will evaluate MME, a culturally based HIV stigma reduction intervention using the "What Matters Most"framework, to reduce stigma and improve treatment adherence among pregnant women and their infants. This study will help inform further refinement of MME and preparation for a future large-scale, multisite, randomized controlled trial (RCT) in Botswana. Trial registration: ClinicalTrials.gov NCT03698981. Registered on October 8, 2018
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 PsychiatryAbstractBackground: 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.
Promoting insight and recovery in the context of the “insight paradox”Yang, L. H., Samuel, S. S., Tay, C., & Cho, Y.
Journal titleSchizophrenia Research
Psychological Impact of Anti-Asian Stigma Due to the COVID-19 Pandemic: A Call for Research, Practice, and Policy ResponsesMisra, S., Le, P. T. D., Goldmann, E., & Yang, L. H.
Journal titlePsychological Trauma: Theory, Research, Practice, and PolicyAbstractThe COVID-19 pandemic is linked to a rise in stigma and discrimination against Chinese and other Asians, which is likely to have a negative impact on mental health, especially when combined with additional outbreak-related stressors. We discuss the need to consider the potential harms of these anti-Asian sentiments during both the height of the pandemic and longer-term recovery through (a) research-examining how it affects mental health and recovery; (b) practice-implementing evidencebased stigma reduction initiatives; and (c) policy-coordinating federal response to anti-Asian racism including investment in mental health services and community-based efforts.
Psychosis risk stigma and help-seeking: Attitudes of Chinese and Taiwanese residing in the United StatesHe, E., Eldeeb, S. Y., Cardemil, E. V., & Yang, L. H.
Journal titleEarly Intervention in Psychiatry
Page(s)97-105AbstractAim: Intervention during the clinical high-risk phase for psychosis (CHR) can reduce duration of untreated psychosis and associated negative outcomes. Early treatment access and sustained engagement are important to understand for effective intervention. Understanding stigma and help-seeking processes is particularly important for groups that experience mental healthcare disparities such as those of Chinese heritage living in the United States. Methods: Chinese and Taiwanese participants (N = 215) residing in the United States were randomly assigned to one of three CHR vignette conditions based on the “what matters most” stigma framework for Chinese groups, which identifies capacities that define “personhood” and thereby shapes stigma for members of a particular cultural group. Participants completed measures of help-seeking attitudes, family stigma and individual stigma. Results: More stigma towards the CHR vignette character's family was associated with positive CHR help-seeking attitudes. Participants who read the vignette describing CHR affecting family obligations, “what matters most” and participants who read the vignette describing CHR symptomology only had more positive CHR help-seeking attitudes compared to participants who read the vignette describing CHR affecting individual aspirations. Conclusions: Chinese and Taiwanese residing in the United States may perceive professional mental healthcare to be especially relevant for persons with CHR when symptoms are particularly stigmatizing for the person's family and when symptoms threaten the person's ability to fulfil family obligations (ie, “what matters most”). Clinical implications of findings include the importance of emphasizing positive treatment outcomes that increase an individual's ability to engage in valued life domains.
Stigma associated with the labeling of schizophrenia, depression, and hikikomori in Japan.DeVylder, J. E., Narita, Z., Horiguchi, S., Kodaka, M., Schiffman, J., Yang, L. H., & Koyanagi, A.
Journal titleStigma and Health
Page(s)472-476AbstractLabeling is a fundamental component of stigma, which allows the identification of features or behaviors that are then stereotyped and made into targets of discrimination. In Japan, the label applied to the condition known in the DSM and International Statistical Classification of Diseases and Related Health Conditions as “schizophrenia” was revised in 2002 from “mind-split disease” to “integration disorder,” intending to alleviate stigma associated with this condition. However, there has been little research examining the effect of the label itself on stigmatizing attitudes, particularly in relation to other mental health conditions, such as depression, or nonclinical cultural idioms of distress, such as hikikomori (i.e., social withdrawal or, literally, “pulling inward”). In this vignette study, we examined the influence of labeling on mental illness stigma by randomizing the label attached to a set of diagnostically ambiguous cases and assessing attitudes regarding these cases among an Internet-based sample of Japanese adults (N = 192). Using within-subjects analysis of variance, we found that both schizophrenia labels, “integration disorder” and “mind-split disease,” were similarly associated with the greatest levels of stereotype awareness but not any other components of stigma. The schizophrenia-labeled cases were also viewed as being more biologically rather than socially caused, compared to depression and hikikomori. Compared to hikikomori, all 3 clinical label conditions (both schizophrenia labels, plus depression) were rated as having a greater need for clinical treatment. Overall, there were no significant differences between the 2 schizophrenia labels on any outcome measure, whereas the nonclinical label was associated with less perceived need for treatment, greater social causation, and less perceived unpredictability. (PsycInfo Database Record (c) 2020 APA, all rights reserved)
The impact of China-to-US immigration on structural and cultural determinants of HIV-related stigma: implications for HIV care of Chinese immigrantsBecker, T. D., Poku, O. B., Chen, X., Wong, J., Mandavia, A., Huang, M., Chen, Y., Huang, D., Ngo, H., & Yang, L. H.
Journal titleEthnicity and Health
Page(s)1-20AbstractObjectives: Asian Americans have poor HIV-related outcomes, yet culturally salient barriers to care remain unclear, limiting development of targeted interventions for this group. We applied the ‘what matters most’ theory of stigma to identify structural and cultural factors that shape the nature of stigma before and after immigration from China to the US. Design: Semi-structured interviews were conducted with 16 immigrants to New York from China, recruited from an HIV clinic and community centers. Deductive followed by focal inductive qualitative analyses examined how Chinese cultural values (lian, guanxi, renqing) and structural factors influenced stigma before and after immigration. Results: In China, HIV stigma was felt through the loss of lian (moral status) and limited guanxi (social network) opportunities. A social structure characterized by limited HIV knowledge, discriminatory treatment from healthcare systems, and human rights violations impinged on the ability of people living with HIV to fulfill culturally valued goals. Upon moving to the US, positions of structural vulnerability shifted to enable maintenance of lian and formation of new guanxi, thus ameliorating aspects of stigma. Conclusions: HIV prevention and stigma reduction interventions among Chinese immigrants may be most effective by both addressing structural constraints and facilitating achievement of cultural values through clinical, peer, and group interventions.