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
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.
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
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 PsychiatryAbstractAim: 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 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
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 BehaviorAbstractPerceived 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.
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.
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.
A new brief opioid stigma scale to assess perceived public attitudes and internalized stigma: Evidence for construct validityYang, L. H., Grivel, M. M., Anderson, B., Bailey, G. L., Opler, M., Wong, L. Y., & Stein, M. D.
Journal titleJournal of Substance Abuse Treatment
Page(s)44-51AbstractOne key strategy to improve treatment access for persons with opioid use disorder (OUD) is overcoming stigma that is internalized by such individuals. Because few theoretically-derived, multidimensional measures of substance abuse stigma exist, we contribute a brief, theoretically-based measure of opioid-related stigma (adapted from Corrigan's Self-Stigma of Mental Illness Scale) to assess perceived stigma and internalized stigma among individuals with OUD. This study presents initial validation of the newly-developed Brief Opioid Stigma Scale among 387 adults who entered an inpatient opioid managed-withdrawal program. The scale assesses: (1) Stereotype awareness (“Aware”), or the extent to which individuals who use opioids perceive community members to believe OUD-related stereotypes; (2) Stereotype agreement (“Agree”), or the endorsement of stigmatizing beliefs by individuals who use opioids; (3) Self-esteem decrement (“Harm”), or the diminution of self-esteem due to these negative stereotypes’ impacts on self-worth. Psychosocial measures including self-esteem, depressive symptoms, mental and physical functioning, and desire for aftercare OUD medication treatment, were administered to assess construct validity. Results showed that greater endorsement of the “harm” stigma subscale was associated with greater depressive symptoms, lower self-esteem, and poorer mental and physical functioning. The “aware” stigma subscale displayed similar overall patterns of associations with self-esteem and depression but to a lesser magnitude. The “aware” stigma subscale was positively associated with desire for aftercare methadone and naltrexone treatment, and the “harm” subscale was positively associated with desire for aftercare buprenorphine treatment. Results indicated good initial construct validity. Tailored stigma interventions are recommended for specific aftercare OUD medication treatments.
A predictive model for conversion to psychosis in clinical high-risk patientsCiarleglio, A. J., Brucato, G., Masucci, M. D., Altschuler, R., Colibazzi, T., Corcoran, C. M., Crump, F. M., Horga, G., Lehembre-Shiah, E., Leong, W., Schobel, S. A., Wall, M. M., Yang, L. H., Lieberman, J. A., & Girgis, R. R.
Journal titlePsychological Medicine
Page(s)1128-1137AbstractBackground The authors developed a practical and clinically useful model to predict the risk of psychosis that utilizes clinical characteristics empirically demonstrated to be strong predictors of conversion to psychosis in clinical high-risk (CHR) individuals. The model is based upon the Structured Interview for Psychosis Risk Syndromes (SIPS) and accompanying clinical interview, and yields scores indicating one's risk of conversion.Methods Baseline data, including demographic and clinical characteristics measured by the SIPS, were obtained on 199 CHR individuals seeking evaluation in the early detection and intervention for mental disorders program at the New York State Psychiatric Institute at Columbia University Medical Center. Each patient was followed for up to 2 years or until they developed a syndromal DSM-4 disorder. A LASSO logistic fitting procedure was used to construct a model for conversion specifically to a psychotic disorder.Results At 2 years, 64 patients (32.2%) converted to a psychotic disorder. The top five variables with relatively large standardized effect sizes included SIPS subscales of visual perceptual abnormalities, dysphoric mood, unusual thought content, disorganized communication, and violent ideation. The concordance index (c-index) was 0.73, indicating a moderately strong ability to discriminate between converters and non-converters.Conclusions The prediction model performed well in classifying converters and non-converters and revealed SIPS measures that are relatively strong predictors of conversion, comparable with the risk calculator published by NAPLS (c-index = 0.71), but requiring only a structured clinical interview. Future work will seek to externally validate the model and enhance its performance with the incorporation of relevant biomarkers.
Impact of “psychosis risk” identification: Examining predictors of how youth view themselvesYang, L. H., Woodberry, K. A., Link, B. G., Corcoran, C. M., Bryant, C., Shapiro, D. I., Downing, D., Girgis, R. R., Brucato, G., Huang, D., Crump, F. M., Verdi, M., McFarlane, W. R., & Seidman, L. J.
Journal titleSchizophrenia Research
Page(s)300-307AbstractBackground: Identifying young people as at clinical high-risk (CHR) for psychosis affords opportunities for intervention to possibly prevent psychosis onset. Yet such CHR identification could plausibly increase stigma. We do not know whether these youth already perceive themselves to be at psychosis-risk (PR) or how their being told they are at PR might impact how they think about themselves. Methods: 148 CHR youth were asked about labels they had been given by others (labeling by others) or with which they personally identified (self-labeling). They were then asked which had the greatest impact on how they thought about themselves. We evaluated whether being told vs. thinking they were at PR had stronger effects. Findings: The majority identified nonpsychotic disorders rather than PR labels as having the greatest impact on sense of self (67.6% vs. 27.7%). However, participants who identified themselves as at PR had an 8.8 (95% CI = 2.0-39.1) increase in the odds of the PR label having the greatest impact (p < 0.01). Additionally, having been told by others that they were at PR was associated with a 4.0 increase in odds (95% CI = 1.1-15.0) that the PR label had the most impact (p < 0.05). Interpretation: Nonpsychotic disorder labels appear to have a greater impact on CHR youth than psychosis-risk labels. However, thinking they are at PR, and, secondarily, being told they are at PR, appears to increase the relative impact of the PR label. Understanding self- and other-labeling may be important to how young people think of themselves, and may inform early intervention strategies.
Implementing a community-based task-shifting psychosocial intervention for individuals with psychosis in Chile: Perspectives from usersAgrest, M., Le, P. T. D., Yang, L. H., Mascayano, F., Alves-Nishioka, S., Dev, S., Kankan, T., Tapia-Muñoz, T., Sawyer, S., Toso-Salman, J., Dishy, G. A., Jorquera, M. J., Schilling, S., Pratt, C., Price, L. S., Valencia, E., Conover, S., Alvarado, R., & Susser, E. S.
Journal titleInternational Journal of Social Psychiatry
Page(s)38-45AbstractBackground: Latin America, and Chile in particular, has a rich tradition of community mental health services and programs. However, in vivo community-based psychosocial interventions, especially those with a recovery-oriented approach, remain scarce in the region. Between 2014 and 2015, a Critical Time Intervention-Task Shifting project (CTI-TS) was implemented in Santiago, Chile, as part of a larger pilot randomized control trial. CTI is a time-limited intervention delivered at a critical-time to users, is organized by phases, focuses on specific objectives and decreases in intensity over time. CTI-TS, which combines both the task-shifting strategy and the use of peers, introduces a novel approach to community mental health care that has not yet been tried in Chile. Aims: We aim to evaluate the feasibility, acceptability and applicability of such a community-based psychosocial intervention in urban settings in Latin America – specifically, in Santiago (Chile) from a user perspective. Method: We analyzed 15 in-depth interviews (n = 15) with service users who participated in the intervention about their perceptions and experiences with CTI-TS through thematic analysis. Results: Three themes were revealed. The first was related to the structural characteristics of CTI-TS, especially regarding the timing, duration and phasic nature of the intervention. The second pertained to the acceptability of the in vivo community-based approach. The third theme dealt with the task-shifting aspect, that is, users’ perceptions of the peer support workers and the community mental health workers. Conclusions: CTI-TS was generally acceptable in this Latin American context. Users’ perspectives pointed to the need to make adjustments to some of the structural characteristics of the CTI model and to combine this type of intervention with others that can address stigma. Thus, future adaptations of CTI-TS or similar psychosocial interventions in Latin American contexts are feasible and can enhance community mental health in the region.
Implementing the protocol of a pilot randomized controlled trial for the recovery-oriented intervention to people with psychoses in two Latin American citiesMascayano, F., Alvarado, R., Andrews, H. F., Jorquera, M. J., Lovisi, G. M., Souza, F. M. D., Pratt, C., Rojas, G., Restrepo-Toro, M. E., Fader, K., Gorroochurn, P., Galea, S., Dahl, C. M., Cintra, J., Conover, S., Burrone, M. S., Baumgartner, J. N., Rosenheck, R., Schilling, S., Sarução, K. R., Stastny, P., Tapia, E., Cavalcanti, M. T., Valencia, E., Yang, L. H., & Susser, E.
Journal titleCadernos de saude publica
Page(s)e00108018AbstractSeveral Latin American countries have made remarkable strides towards offering community mental health care for people with psychoses. Nonetheless, mental health clinics generally have a very limited outreach in the community, tending to have weaker links to primary health care; rarely engaging patients in providing care; and usually not providing recovery-oriented services. This paper describes a pilot randomized controlled trial (RCT) of Critical Time Intervention-Task Shifting (CTI-TS) aimed at addressing such limitations. The pilot RCT was conducted in Santiago (Chile) and Rio de Janeiro (Brazil). We included 110 people with psychosis in the study, who were recruited at the time of entry into community mental health clinics. Trial participants were randomly divided into CTI-TS intervention and usual care. Those allocated to the intervention group received usual care and, in addition, CTI-TS services over a 9-month period. Primary outcomes include quality of life (WHO Quality of Life Scale - Brief Version) and unmet needs (Camberwell Assessment of Needs) at the 18-month follow-up. Primary outcomes at 18 months will be analyzed by Generalized Estimating Equations (GEE), with observations clustered within sites. We will use three-level multilevel models to examine time trends on the primary outcomes. Similar procedures will be used for analyzing secondary outcomes. Our hope is that this trial provides a foundation for planning a large-scale multi-site RCT to establish the efficacy of recovery-oriented interventions such as CTI-TS in Latin America.
Mental health service use among asian americans five to six years after exposure to the world trade center attackKung, W. W., Goldmann, E., Liu, X., Wang, X., Huang, D., & Yang, L. H.
Journal titleSocial Service Review
Page(s)96-128AbstractThis study uses World Trade Center Health Registry data, based on Andersen’s health-care model, to investigate 2,557 Asians’ mental health service use and associated factors 5–6 years after the World Trade Center attack, compared against 32,111 non-Hispanic white participants. We find that Asians had a lower proportion of service use (15.76 vs. 26.60 percent) than white people. A previous mental health diagnosis and perceived and evaluated mental health needs strongly predicted Asians’ mental health service use, as did having routine medical checkups, being female, and being married or cohabiting. These factors, in addition to other socioeconomic predictors that were nonsignificant among Asians, were significant among white people, as well. Our findings suggest that service providers need to provide clear diagnoses to service users, explore mental health needs during medical checkups, and provide postdisaster mental health education and free treatment.
Out of the silos: Identifying cross-cutting features of health-related stigma to advance measurement and interventionVan Brakel, W. H., Cataldo, J., Grover, S., Kohrt, B. A., Nyblade, L., Stockton, M., Wouters, E., & Yang, L. H.
Journal titleBMC Medicine
Issue1AbstractBackground: Many health conditions perceived to be contagious, dangerous or incurable, or resulting in clearly visible signs, share a common attribute - an association with stigma and discrimination. While the etiology of stigma may differ between conditions and, sometimes, cultural settings, the manifestations and psychosocial consequences of stigma and discrimination are remarkably similar. However, the vast majority of studies measuring stigma or addressing stigma through interventions employ a disease-specific approach. Main body: The current paper opposes this siloed approach and advocates a generic concept of 'health-related stigma' in both stigma measurement and stigma interventions. Employing a conceptual model adapted from Weiss, the current paper demonstrates the commonalities among several major stigmatized conditions by examining how several stigma measurement instruments, such as the Social Distance Scale, Explanatory Model Interview Catalogue, Internalized Stigma of Mental Illness, and Berger stigma scale, and stigma reduction interventions, such as information-based approaches, contact with affected persons, (peer) counselling, and skills building and empowerment, were used successfully across a variety of conditions to measure or address stigma. The results demonstrate that 'health-related stigma' is a viable concept with clearly identifiable characteristics that are similar across a variety of stigmatized health conditions in very diverse cultures. Conclusion: A more generic approach to the study of health-related stigma opens up important practical opportunities - cross-cutting measurement and intervention tools are resource saving and easier to use for personnel working with multiple conditions, allow for comparison between conditions, and recognize the intersectionality of many types of stigma. Further research is needed to build additional evidence demonstrating the advantages and effectiveness of cross-condition approaches to stigma measurement and interventions.
Self-stigma related feelings of shame and facial fear recognition in individuals at clinical high risk for psychosis: A brief reportLarsen, E. M., Herrera, S., Bilgrami, Z. R., Shaik, R. B., Crump, F., Sarac, C., Shen, J., Yang, L. H., & Corcoran, C. M. In Schizophrenia Research.
Understanding the public's profile of mental health literacy in China: A nationwide studyHuang, D., Yang, L. H., & Pescosolido, B. A.
Journal titleBMC psychiatry
Issue1AbstractBackground: In the wake of China's massive economic development, attention has only recently turned to the enormous treatment gap that exists for mental health problems. Our study is the first comprehensive, national examination of the levels and correlates of the public's ability to recognize mental illness in the community and suggest sources of help, setting a baseline to assess contemporary Chinese efforts. Methods: Data were collected in China as part of the Stigma in Global Context - Mental Health Study (SGC-MHS) through face-to-face interviews using vignettes meeting clinical criteria for schizophrenia and major depression. Our analysis targets the Han Chinese participants (n = 1812). Differences in the recognition of mental health problems were assessed using a chi-square test and further stratified by vignette illness type and urban vs. rural residence. Adjusted regression models estimated the effects of each predictor towards the endorsement three types of help-seeking: medical doctor, psychiatrist, and mental health professional. Results: As expected, recognition of mental health problems is low; it is better for depression and most accurate in urban areas. Perceived severity increases endorsement of the need for care and for treatment by all provider types. Recognition of a mental health problem specifically decreases endorsement of medical doctors while increasing recommendations for psychiatrists and mental health professionals. Neurobiological attributions decrease recommendations for mental health professionals as opposed to general or specialty physicians. Conclusions: Continued efforts are needed in China to promote mental illness recognition within rural areas, and of schizophrenia specifically. Promoting recognition of mental illness, while balancing the special challenges among individuals who understand the neurobiological roots of mental illness, may constitute a key strategy to reduce the sizeable mental health treatment gap in China.
“It’s When the Trees Blossom”: Explanatory Beliefs, Stigma, and Mental Illness in the Context of HIV in BotswanaBecker, T. D., Ho-Foster, A. R., Poku, O. B., Marobela, S., Mehta, H., Cao, D. T. X., Yang, L. S., Blank, L. I., Dipatane, V. I., Moeng, L. R., Molebatsi, K., Eisenberg, M. M., Barg, F. K., Blank, M. B., Opondo, P. R., & Yang, L. H.
Journal titleQualitative Health Research
Page(s)1566-1580AbstractMental illness is a common comorbidity of HIV and complicates treatment. In Botswana, stigma impedes treatment of mental illness. We examined explanatory beliefs about mental illness, stigma, and interactions between HIV and mental illness among 42 adults, from HIV clinic and community settings, via thematic analysis of interviews. Respondents endorse witchcraft as a predominant causal belief, in addition to drug abuse and effects of HIV. Respondents describe mental illness as occurring “when the trees blossom,” underscoring a conceptualization of it as seasonal, chronic, and often incurable and as worse than HIV. Consequently, people experiencing mental illness (PEMI) are stereotyped as dangerous, untrustworthy, and cognitively impaired and discriminated against in the workplace, relationships, and sexually, increasing vulnerability to HIV. Clinical services that address local beliefs and unique vulnerabilities of PEMI to HIV, integration with peer support and traditional healers, and rehabilitation may best address the syndemic by facilitating culturally consistent recovery-oriented care.
Criminal victimization and psychotic experiences: cross-sectional associations in 35 low- and middle-income countriesDeVylder, J. E., Kelleher, I., Oh, H., Link, B. G., Yang, L. H., & Koyanagi, A.
Journal titleActa Psychiatrica Scandinavica
Page(s)44-54AbstractObjective: Criminal victimization has been associated with elevated risk for psychotic symptoms in the United Kingdom, but has not been studied in low- and middle-income countries (LMICs). Understanding whether crime exposure may play a role in the social etiology of psychosis could help guide prevention and intervention efforts. Method: We tested the hypothesis that criminal victimization would be associated with elevated odds of psychotic experiences in 35 LMICs (N = 146 999) using cross-sectional data from the World Health Organization World Health Survey. Multivariable logistic regression analyses were used to test for associations between criminal victimization and psychotic experiences. Results: Victimization was associated with greater odds of psychotic experiences, OR (95% CI) = 1.72 (1.50–1.98), and was significantly more strongly associated with psychotic experiences in non-urban, OR (95% CI) = 1.93 (1.60–2.33), compared to urban settings, OR (95% CI) = 1.48 (1.21–1.81). The association between victimization and psychosis did not change across countries with varying aggregated levels of criminal victimization. Conclusions: In the largest ever study of victimization and psychosis, the association between criminal victimization and psychosis appears to generalize across a range of LMICs and, therefore, across nations with a broad range of crime rates, degree of urban development, average per capita income, and racial/ethnic make-up.
Depressive symptoms and their association with social determinants and chronic diseases in middle-aged and elderly Chinese peopleLiu, Q., Cai, H., Yang, L. H., Xiang, Y. B., Yang, G., Li, H., Gao, Y. T., Zheng, W., Susser, E., & Shu, X. O.
Journal titleScientific reports
Issue1AbstractDepression is one of the most prevalent mental disorders worldwide. Little information is available regarding association of depressive symptoms (DS) with cancer and chronic diseases among middle-aged and elderly Chinese in a population-based setting. In this study we evaluated the prevalence and examined correlates of DS in two population-based cohort studies. Included in the analyses were 103,595 people with a mean age of 61.8 years at the DS assessment. The prevalence of DS was 2.4% in men and 5.6% in women. We found elderly participants, those with lower BMI, or chronic diseases were more likely to experience DS. Having a history of stroke (odds ratio (OR) = 2.2 in men and 1.8 in women), cancer (OR = 3.3 in men and 1.9 in women), or Parkinson's disease (OR = 3.1 in men and 2.7 in women) was associated with high DS. In women, high income and high education levels were inversely related to DS. Being a single woman, long-term or heavy female smoker was associated with high prevalence of DS. High BMI was correlated with low prevalence of depression in men. Our data suggests a low prevalence of DS among middle-aged and elderly people in Shanghai, China. Age, education, income, marital status, smoking, BMI, and certain health conditions were associated with DS.