title: Mental health-related stigma and pathways to care for people at risk of psychotic disorders or experiencing first-episode psychosis: a systematic review.
abstract: BACKGROUND
  Stigma associated with mental illness can delay or prevent help-seeking and service contact. Stigma-related influences on pathways to care in the early stages of psychotic disorders have not been systematically examined.
  
  
  METHODS
  This review systematically assessed findings from qualitative, quantitative and mixed-methods research studies on the relationship between stigma and pathways to care (i.e. processes associated with help-seeking and health service contact) among people experiencing first-episode psychosis or at clinically defined increased risk of developing psychotic disorder. Forty studies were identified through searches of electronic databases (CINAHL, EMBASE, Medline, PsycINFO, Sociological Abstracts) from 1996 to 2016, supplemented by reference searches and expert consultations. Data synthesis involved thematic analysis of qualitative findings, narrative synthesis of quantitative findings, and a meta-synthesis combining these results.
  
  
  RESULTS
  The meta-synthesis identified six themes in relation to stigma on pathways to care among the target population: 'sense of difference', 'characterizing difference negatively', 'negative reactions (anticipated and experienced)', 'strategies', 'lack of knowledge and understanding', and 'service-related factors'. This synthesis constitutes a comprehensive overview of the current evidence regarding stigma and pathways to care at early stages of psychotic disorders, and illustrates the complex manner in which stigma-related processes can influence help-seeking and service contact among first-episode psychosis and at-risk groups.
  
  
  CONCLUSIONS
  Our findings can serve as a foundation for future research in the area, and inform early intervention efforts and approaches to mitigate stigma-related concerns that currently influence recognition of early difficulties and contribute to delayed help-seeking and access to care.
authors.affiliation: Health Service and Population Research Department,Institute of Psychiatry, Psychology & Neuroscience, King's College London,London,UK.
authors.forename: P C
authors.initials: PC
authors.lastname: Gronholm
authors.affiliation: Health Service and Population Research Department,Institute of Psychiatry, Psychology & Neuroscience, King's College London,London,UK.
authors.forename: G
authors.initials: G
authors.lastname: Thornicroft
authors.affiliation: Department of Forensic and Neurodevelopmental Science,Institute of Psychiatry, Psychology & Neuroscience, King's College London,London,UK.
authors.forename: K R
authors.initials: KR
authors.lastname: Laurens
authors.affiliation: Health Service and Population Research Department,Institute of Psychiatry, Psychology & Neuroscience, King's College London,London,UK.
authors.forename: S
authors.initials: S
authors.lastname: Evans-Lacko
mesh_terms: D006801:Humans; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D011618:Psychotic Disorders / Q000523:psychology* / Q000628:therapy*; D057545:Social Stigma
keywords: Discrimination; FEP; early intervention; healthcare utilization; healthcare-seeking behaviour; help-seeking behaviour; labelling; literature review; stigma; treatment barriers