title: Mental health-related discrimination as a predictor of low engagement with mental health services.
abstract: OBJECTIVE
  This study aimed to test the hypothesis that mental health-related discrimination experienced by adults receiving care from community mental health teams is associated with low engagement with services and to explore the pathways between these two variables.
  
  
  METHODS
  In this cross-sectional study, 202 adults registered with inner-city community mental health teams in the United Kingdom completed interviews assessing their engagement with mental health services (service user-rated version of the Service Engagement Scale), discrimination that they experienced because of mental illness, and other variables. Structural equation modeling was conducted to examine the relationship of experienced discrimination and service engagement with potential mediating and moderating variables, such as anticipated discrimination (Questionnaire on Anticipated Discrimination), internalized stigma (Internalized Stigma of Mental Illness Scale), stigma stress appraisal (Stigma Stress Appraisal), mistrust in services, the therapeutic relationship (Scale to Assess Therapeutic Relationships), difficulty disclosing information about one's mental health, and social support. Analyses controlled for age, race-ethnicity, and symptomatology.
  
  
  RESULTS
  No evidence was found for a direct effect between experienced discrimination and service engagement. The total indirect effect of experienced discrimination on service engagement was statistically significant (coefficient=1.055, 95% confidence interval [CI]=.312-2.074, p=.019), mainly via mistrust in mental health services and therapeutic relationships (coefficient=.804, CI=.295-1.558, p=.019). A 1-unit increase in experienced discrimination via this pathway resulted in .804-unit of deterioration in service engagement.
  
  
  CONCLUSIONS
  Findings indicate the importance of building and maintaining service users' trust in mental health services and in therapeutic relationships with professionals and countering the discrimination that may erode trust.
authors: Except for Dr. Hatch, the authors are with the Department of Health Services and Population Research, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, United Kingdom (e-mail: sarah.clement@kcl.ac.uk ). Dr. Hatch is with the Department of Psychological Medicine, King's College London.
authors: Sarah
authors: S
authors: Clement
authors: Paul
authors: P
authors: Williams
authors: Simone
authors: S
authors: Farrelly
authors: Stephani L
authors: SL
authors: Hatch
authors: Oliver
authors: O
authors: Schauman
authors: Debra
authors: D
authors: Jeffery
authors: R Claire
authors: RC
authors: Henderson
authors: Graham
authors: G
authors: Thornicroft
mesh_terms: D000328:Adult; D000368:Aged; D003156:Community Mental Health Services / Q000706:statistics & numerical data*; D004739:England; D005260:Female; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000523:psychology* / Q000628:therapy; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D011287:Prejudice; D011369:Professional-Patient Relations; D012650:Self Disclosure; D057545:Social Stigma; D012944:Social Support; D055815:Young Adult