Mind matters: How destigmatisation drives help-seeking in Nepal

Common mental health problems such as anxiety and depression constitute a significant public health challenge, with stigma being a key barrier to seeking proper care. Based on a study in Nepal, the article shows that low-cost, well-targeted interventions such as information campaigns or celebrity endorsements, can encourage people to seek support and bridge the gaps in treatment.

Mental health issues, especially anxiety and depression, are some of the most common health challenges worldwide. Over a billion people experience mental health problems, but nearly half of them do not receive treatment (United Nations News, 2022). In low- and middle-income countries, this gap is even more pronounced, with up to 75% of individuals suffering from mental health issues not receiving proper care (Kovacevic 2021). This creates a public health challenge, especially because untreated mental health problems can lead to worsened physical health, economic hardship, and reduced well-being.

A key barrier to seeking care for mental health issues is stigma. This raises an important question: can targeted interventions to reduce stigma increase people’s willingness to seek mental health support? We explore this in Nepal, a low-resource setting. Our study aims to determine whether stigma reduction strategies can bridge the gap between the high incidence of mental health issues and the low proportions that receive care (Lacey et al. 2024).

Local context

In Nepal, stigma around mental health issues and services are common. Like in many other parts of the world, people in Nepal often view mental illness negatively. In our study, we interviewed 2,485 participants over the phone. These interviews included questions about their mental health as well as their attitudes toward mental illness and mental healthcare They told us that they fear being judged, discrimination against, or seen as weak if they seek help. This anticipation of stigma stops many from taking the first step toward treatment. Additionally, some hold personal stigma, where they themselves believe that mental health issues are a sign of personal failure. In such environments, even those who know they need help may avoid seeking it. As a result, less than 10% of individuals with mental health issues receive adequate treatment (Jordans et al. 2019).

Testing two approaches to reducing stigma

After the interview, we randomly assigned the participants to one of three groups: two ‘treatment’ groups (subject to intervention) received different forms of stigma-reduction messages, while a ‘control’ group received no intervention. These messages were delivered on the same phone call as the interview.

The two interventions were designed to reduce stigma in different ways:

i) Information-based intervention: In this group, we shared general information about the prevalence and treatability of mental health issues. We highlighted that mental health problems, like depression and anxiety, are common and can affect anyone. We also reframed the act of seeking help as a sign of strength, countering the notion that it is a sign of weakness.

ii) Celebrity disclosure intervention: In this group, we shared the story of a popular Nepali celebrity who had struggled with mental health issues but overcame them with treatment. By showing that even successful and admired individuals can experience mental health challenges, this intervention aimed to reduce the fear of judgment, or anticipated stigma, that often prevents people from seeking help.

After delivering these messages, we asked participants (in both the treatment and control groups) how willing they would be to seek mental health treatment if they were experiencing emotional distress. We wanted to see if the interventions changed their willingness to seek care.¹

Key findings: Reducing stigma boosts willingness to seek help

Our findings showed that both interventions were effective. Participants who received either the information-based message or the celebrity story were 0.11 standard deviations (SD)²more likely to express a willingness to seek help compared to those in the control group.

This may seem like a small effect, but it is consistent with what we know about the powerful role that stigma plays in mental healthcare. Even modest shifts in attitudes can have significant public health implications, especially in settings where stigma is deeply entrenched.

Who benefits the most? The impact on high-stigma individuals

One of the key insights from our study is that the interventions were particularly effective for participants who held high levels of personal or anticipated stigma. Those who initially had the strongest negative views about mental health issues, or who feared being judged for seeking help, were the ones who responded most positively to the interventions.

This finding is crucial because it shows that even those who are most resistant to seeking help – due to stigma – can be influenced by well-crafted messages. Breaking down these barriers in high-stigma populations could lead to more widespread help-seeking behaviors.

Additionally, we found that participants with milder symptoms of anxiety and depression were more responsive to the interventions. This suggests that early intervention may be key – reaching people when they are experiencing mild distress could prevent their symptoms from worsening and make them more likely to seek help.

Gender dynamics: The role of enumerator gender

Another important finding from our study was the influence of the enumerator’s gender on participants’ willingness to seek help. The research finds that respondents were significantly more open when speaking with female enumerators, demonstrating a 0.07 SD higher willingness to seek counselling and being 0.13 SD more likely to disclose mental health issues. Participants also reported feeling 0.09 SD more comfortable during calls with female enumerators. Notably, while female enumerators created a more comfortable environment for mental health discussions, they did not amplify or diminish the impact of the study's main information interventions. These findings have important implications for designing mental health surveys and interventions, as they suggest that female enumerators may be particularly effective in contexts where stigma and discomfort around mental health discussions are prevalent.

Implications for mental health policy

The findings from this study have significant implications for mental health policy in low-resource settings like Nepal. First, we demonstrated that low-cost, scalable interventions can effectively reduce stigma and increase willingness to seek mental healthcare. These types of interventions – delivered through information campaigns or celebrity endorsements – could be crucial in countries where mental health resources are limited but stigma is high.

Second, our research highlights the importance of targeting individuals with mild mental health symptoms. Early intervention may have the greatest impact, as it helps people seek help before their conditions worsen.

Finally, the success of the celebrity disclosure intervention suggests that leveraging well-known public figures in mental health campaigns can be an effective way to reduce stigma. By sharing their stories, celebrities can make mental health struggles more relatable and encourage others to seek the help they need.

Conclusion: Destigmatising mental health, one message at a time

Our study shows that even modest, well-targeted interventions can make a meaningful difference in reducing the stigma around mental health and encouraging people to seek help. In Nepal, where stigma remains a major barrier to mental healthcare, these interventions could play a crucial role in improving access to treatment.

Note:

The results from our heterogeneity analysis become even more useful in understanding whether or not there is surveyor bias. If surveyor bias was driving all our results, then we perhaps would not see heterogeneity in effects across subsamples. However, the fact that the effects are highest among those with high initial levels of stigma suggests that there might be something beyond surveyor bias.
Standard deviation is a measure used to quantify the amount of variation or dispersion of a set of values from the mean (average) value of that set.