A school curriculum–based intervention aimed at reducing the stigma of mental illness was associated with a nearly fourfold increase in the likelihood of youth with significant symptoms seeking treatment.

A girl and her classmates write in class Ridofranz/Getty Images

Writing in Pediatrics, researchers reported the outcome of a 2-year, longitudinal, cluster-randomized trial involving 416 students in sixth-grade classes in 14 schools across Texas.

The intervention was a school-based curriculum program called Eliminating the Stigma of Differences (ESD); a 3-hour, three-module curriculum program delivered over 1 week, which contained a mix of teaching, group discussion, and homework exercises.

One module explored the idea of difference; the definition, causes and consequences of stigma; ways to end stigma; and the description, causes and treatments of mental illness as well as the barriers to seeking help. The other two modules explored specific mental illnesses in more detail but with content designed to stimulate empathy.

The study compared this with two other interventions – in-class presentations and discussions led by two young adults with a history of mental illness; or exposure to anti-stigma printed materials – and a no-intervention control.

The study found that involvement with the curriculum program was associated with a significant and sustained increase in knowledge of and attitudes to mental illness compared with the control and other interventions, and with significant decreases in social distance, which measures the extent to which children are unwilling to interact with someone who is identified as having a mental illness. This association was seen even after the researchers controlled for other factors such as a participants’ knowledge of or attitudes toward mental illness before the intervention, their age, sex, race or ethnicity, or their parents’ educational level.

“Our study, in combination with other studies, suggests strongly that youth can be positively influenced at a relatively young age, fostering changes in mental health attitudes and behaviors that last, as our study has shown, for at least 2 years,” wrote Bruce G. Link, PhD, of the School of Public Policy at the University of California, Riverside, and coauthors.

The study also found that among youth who were experiencing a high level of symptoms of mental illness, the curriculum-based intervention was associated with nearly fourfold higher odds of seeking treatment (odd ratio 3.9, P < .05), after adjustment for similar covariates.

The authors looked separately at whether this self-reported treatment-seeking was the first time that students had sought treatment, a continuation of treatment seeking, or a return to it. All three showed similar odds ratios but small sample sizes meant they did not reach statistical significance.

“We do know that negative attitudes toward mental illnesses and the exceptionally large percentage of people who experience but do not receive treatment for such illnesses are problems that have been with us for a long time,” Dr. Link and associates said. “Interventions such as ESD represent a partial but positive response to this public mental health challenge.”

The intervention didn’t lead to a significant increase in treatment-seeking behavior among students with low levels of mental illness symptoms.

There were no significant differences in the effectiveness of the intervention across race or ethnicity, sex, education level of caregivers, or the baseline attitudes toward mental illness. The only exception was seen with Latino youth, where the intervention was not associated with a decrease in social distancing.

Contact intervention, in which two young people with a history of mental illness came to talk to classes and participate in discussions, was not associated with any significant changes in attitudes.

“A potential explanation is that contact is not as effective in youth, a possibility that is supported by a meta-analysis showing diminished effects of contact compared with educational interventions in adolescents,” Dr. Link and associates said.

In an accompanying editorial, Nathaniel Beers, MD, of Children’s National Hospital in Washington, and Dr. Shashank V. Joshi, MD, of Stanford (Calif.) University, wrote that more than one-fifth of children and youth in the United States are diagnosed with behavioral health needs before they reach the age of 18, but the perception of stigma can make families reluctant to access treatment.

“Previous research has highlighted the importance of stigma reduction in school-based settings as a crucial component in changing the social norms about seeking help among diverse youth populations,” they said. Reducing stigma also can reduce detrimental outcomes from social isolation and bullying.

Dr. Beers and Dr. Joshi noted that school-based interventions can have a substantial and lasting effect, with the benefit of influencing parents and staff in addition to students.

“Combined with screening and improved access to school-based mental health services, this curriculum could add a critical component to addressing the mental health needs of children and youth in the United States,” they concluded.

The study was supported by the National Institute of Mental Health and National Institutes of Health. The authors said they had no relevant financial disclosures. Dr. Beers and Dr. Joshi received no external funding, and they said they had no relevant financial disclosures.

SOURCES: Link B. et al. Pediatrics 2020, May 20. doi: 10.1542/peds.2019-0780; Beers N and Joshi SV. Pediatrics. 2020, May 20. doi: 10.1542/peds.2020-0127.