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Several protective factors for mitigating suicidal ideation (SI) such as positive affect, reasons for living, purpose in life, meaning in life, gratitude, grit, optimism, social support, and hope have been identified and received empirical support. However, few studies have examined the interrelationships of these protective factors and the identification of protective factors most closely linked to lower levels of SI may be useful for both theory-building initiatives and improvement of suicide-specific interventions. Network analysis offers an approach for testing the relation among these constructs, SI, and suicide risk factors.A sampleThe resulting inferred network implicates strong negative influence of suicide cognitions, but not recent SI, and the strong positive influence of presence of meaning in life, trait hope, and low negative affect.Implications for dimensionality of SI versus suicide cognitions, targeting presence of meaning in life, trait hope, and negative affect in treatment, and cross-cultural variations in reasons for living are discussed. The study is limited by the cross-sectional and convenience sampling methodology.HighlightsProtective factors may have less direct influence on suicidal ideationSuicide cognitions and the suicidal mode may be of phenomenological importancePresence of meaning and trait hope may be primary targets for suicide interventions.

Purpose: Meibomian gland dysfunction disrupts tear film homeostasis and results in dry eye syndrome. The objective of this study is to determine whether transcutaneous radiofrequency (RF)-assisted meibomian gland expression, using the Envision platform and Forma-I handpiece is an effective treatment for dry eye syndrome. Methods: A multicenter prospective cohort study of patients with dry eye undergoing RF-assisted meibomian gland expression was completed from October 2019 to June 2022. The study was designed with multiple primary endpoints. These were defined as the change in Standard Patient Evaluation of Eye Dryness (SPEED) score, changes in Ocular Surface Disease Index (OSDI), Tear Breakup Time (TBUT), Corneal Fluorescence Score (CFS), and Meibomian Gland Score (MGS) at 1, 3, and 6 months after treatment. Secondary endpoints were measurements of patients' subjective improvement and subjective satisfaction with the treatment. Results: A total number of 47 patients were enrolled in the study at three separate institutions by three ophthalmologists (oculoplastics, refractive, and general). However, not all subjects had complete data on all observations at all time points following treatment. When a data point was missing, the entire patient’s outcome for that data set was excluded from the analysis. There was a significant improvement in SPEED score from baseline, 15.7 vs 11.4 at 1 month, 9.1 at 3 months, and 9.6 at 6 months (p Conclusion: This pilot study demonstrates that RF treatment with the Forma-I handpiece along with meibomian gland expression is an effective means to reduce the signs and symptoms of dry eye disease. The data support the conclusion that the treatment is safe and effective, lasting at least 6 months in most patients.

SummaryIn this analysis, we argue that the ‘treatment gap’ for common mental disorders often reflects lack of demand, arising because services fail to address the needs of disadvantaged communities. We propose a route forward for global mental health, with explicit focus on action on the socioeconomic determinants of psychological suffering.

Purpose of review: There is increasing interest in the links between exposure to air pollution and a range of health outcomes. The association with mental health however is much less established. This article reviews developments in the field over the past 12 months, highlighting the evidence for causation, associations between multiple air pollutants and mental health outcomes, and assesses the challenges of researching this topic. Recent findings: Increasingly rigorous methods are being applied to the investigation of a broader range of mental health outcomes. These methods include basic science, neuroimaging, and observational studies representing diverse geographical locations. Cohort studies with linked high resolution air pollutant exposure data are common, facilitating advanced analytic methods. To date meta-analyses have demonstrated small and significant positive associations between long-term exposure to fine particulate matter and depressive symptoms and cognitive decline. Methodological complexities in measuring exposure and outcome pose ongoing difficulties for the field. Summary: Literature on this topic has recently seen an appreciable expansion. Work that better estimates daily exposure, controls for complex confounders, and is driven by hypotheses founded in candidate causal mechanisms would help clarify associations, and inform targeted interventions and policy makers.

We show that if a finite non-collinear set of points in $$\mathbb {C}^2$$ lies on a family of m concurrent lines, and if one of those lines contains more than $$m-2$$ points, there exists a line passing through exactly two points of the set. The bound $$m-2$$ in our result is optimal. Our main theorem resolves a conjecture of Frank de Zeeuw, and generalizes a result of Kelly and Nwankpa.

Applied to a nonnegative $m\times n$ matrix with a nonzero $\sigma$-diagonal, the sequence of matrices constructed by alternate row and column scaling conveges to a doubly stochastic matrix. It is proved that if this sequence converges after only a finite number of scalings, then it converges after at most two scalings., Comment: Corrected typo in statement of Theorem 1; 6 pages

Solving the opioid crisis requires immediate, innovative, and sustainable solutions. A number of promising strategies are being carried out by U.S. states and territories as part of their Opioid State Targeted Response (STR) plans funded through the 21(st) Century Cures Act, and they provide an opportunity for researchers to assess effectiveness of these interventions using pragmatic approaches. This paper describes a pilot study of Project Planned Outreach, Intervention, Naloxone, and Treatment (POINT), the intervention that served as the basis for Indiana’s STR-funded, emergency department (ED)-based peer specialist expansion that was conducted in preparation for a larger, multisite pragmatic trial. Through the pilot, we identified, documented, and corrected for challenges encountered while implementing planned study protocols. Per the project’s funding mechanism, the ability to move to the larger trial was determined by the achievement of 3 milestones: (1) successful replication of the intervention; (2) demonstrated ability to obtain the necessary sample size; and (3) observe a higher level of engagement in medication for addiction treatment in the POINT group compared to standard care. Overall implementation of the study protocols was successful, with only minor refinements to proposed procedures being required in light of challenges with (1) data access, (2) recruitment, and (3) identification of the expansion hospitals. All three milestones were reached. Challenges in implementing protocols and reaching milestones resulted in refinements that improved the study design overall. The subsequent trial will add to the limited but growing evidence on ED-based peer supports. Capitalizing on STR efforts to study an already scaling and promising intervention is likely to lead to faster and more sustainable results with greater generalizability than traditional, efficacy-focused clinical research.

ImportanceLess than 10% of research on psychotic disorders has been conducted in settings in the Global South, which refers broadly to the regions of Latin America, Asia, Africa, and Oceania. There is a lack of basic epidemiological data on the distribution of and risks for psychoses that can inform the development of services in many parts of the world.ObjectiveTo compare demographic and clinical profiles of cohorts of cases and rates of untreated psychoses (proxy for incidence) across and within 3 economically and socially diverse settings in the Global South. Two hypotheses were tested: (1) demographic and clinical profiles of cases with an untreated psychotic disorder vary across setting and (2) rates of untreated psychotic disorders vary across and within setting by clinical and demographic group.Design, Setting, and ParticipantsThe International Research Program on Psychotic Disorders in Diverse Settings (INTREPID II) comprises incidence, case-control, and cohort studies of untreated psychoses in catchment areas in 3 countries in the Global South: Kancheepuram District, India; Ibadan, Nigeria; and northern Trinidad. Participants were individuals with an untreated psychotic disorder. This incidence study was conducted from May 1, 2018, to July 31, 2020. In each setting, comprehensive systems were implemented to identify and assess all individuals with an untreated psychosis during a 2-year period. Data were analyzed from January 1 to May 1, 2022.Main Outcomes and MeasuresThe presence of an untreated psychotic disorder, assessed using the Schedules for Clinical Assessment in Neuropsychiatry, which incorporate the Present State Examination.ResultsIdentified were a total of 1038 cases, including 64 through leakage studies (Kancheepuram: 268; median [IQR] age, 42 [33-50] years; 154 women [57.5%]; 114 men [42.5%]; Ibadan: 196; median [IQR] age, 34 [26-41] years; 93 women [47.4%]; 103 men [52.6%]; Trinidad: 574; median [IQR] age, 30 [23-40] years; 235 women [40.9%]; 339 men [59.1%]). Marked variations were found across and within settings in the sex, age, and clinical profiles of cases (eg, lower percentage of men, older age at onset, longer duration of psychosis, and lower percentage of affective psychosis in Kancheepuram compared with Ibadan and Trinidad) and in rates of untreated psychosis. Age- and sex-standardized rates of untreated psychoses were approximately 3 times higher in Trinidad (59.1/100 000 person-years; 95% CI, 54.2-64.0) compared with Kancheepuram (20.7/100 000 person-years; 95% CI, 18.2-23.2) and Ibadan (14.4/100 000 person-years; 95% CI, 12.3-16.5). In Trinidad, rates were approximately 2 times higher in the African Trinidadian population (85.4/100 000 person-years; 95% CI, 76.0-94.9) compared with the Indian Trinidadian (43.9/100 000 person-years; 95% CI, 35.7-52.2) and mixed populations (50.7/100 000 person-years; 95% CI, 42.0-59.5).Conclusions and RelevanceThis analysis adds to research that suggests that core aspects of psychosis vary by historic, economic, and social context, with far-reaching implications for understanding and treatment of psychoses globally.

OBJECTIVE: As a sequel to the Depression in Later Life trial of lay counselor-delivered problem-solving therapy for depression prevention among older adults in Goa, India, this qualitative study aimed to explore participant experiences to illuminate the reasons for the trial's positive findings and implications for further efforts at depression prevention in low-resource settings. METHODS: In-depth interviews were conducted with 19 participants (21% of those randomly assigned to the original intervention). Two independent raters coded the data and organized narratives according to broad themes. RESULTS: Most participants valued their relationship with the lay counselor, learned self-care strategies to cope with illnesses, and increased engagement in pleasurable social and physical activities. Some participants reported needing assistance with managing financial strain and family conflicts. CONCLUSIONS: The lay-counselor-delivered intervention was well received. The relationship with the counselor and behavioral activation toward better self-care and more-pleasurable activities may have been keys to the intervention's success.

I provide a new method for correcting and assessing bias from measurement error in land area and apply it to estimating two important sets of parameters: the relationship between farm size ...

BACKGROUND: In recent years, a number of emergency department (ED)-based interventions have been developed to provide supports and/or treatment linkage for people who use opioids. However, there is limited research supporting the effectiveness of the majority of these interventions. Project POINT is an ED-based intervention aimed at providing opioid overdose survivors with naloxone and recovery supports and connecting them to evidence-based medications for opioid use disorder (MOUD). An evaluation of POINT was conducted. METHODS: A difference-in-difference analysis of electronic health record data was completed to understand the difference in outcomes for patients admitted to the ED when a POINT staff member was working versus times when they were not. The observation window was January 1, 2012 to July 6, 2019, which included N = 1462 unique individuals, of which 802 were in the POINT arm. Outcomes of focus include MOUD opioid prescriptions dispensed, active non-MOUD opioid prescriptions dispensed, naloxone access, and drug poisonings. RESULTS: The POINT arm had a significant increase in MOUD prescriptions dispensed, non-MOUD prescriptions dispensed, and naloxone access (all p-values < 0.001). There was no significant effect related to subsequent drug poisoning-related hospital admissions. CONCLUSIONS: The results support the assertion that POINT is meeting its two primary goals related to increasing naloxone access and connecting patients to MOUD. Generalization of these results is limited; however, the evaluation contributes to a nascent area of research and can serve a foundation for future work.

We prove that the slice rank of a 3-tensor (a combinatorial notion introduced by Tao in the context of the cap-set problem), the analytic rank (a Fourier-theoretic notion introduced by Gowers and Wolf), and the geometric rank (an algebro-geometric notion introduced by Kopparty, Moshkovitz, and Zuiddam) are all equal up to an absolute constant. As a corollary, we obtain strong trade-offs on the arithmetic complexity of a biased bilinear map, and on the separation between computing a bilinear map exactly and on average. Our result settles open questions of Haramaty and Shpilka [STOC 2010], and of Lovett [Discrete Anal. 2019] for 3-tensors., Published version for Discrete Analysis

Comorbid physical illness is a common cause of death in people with severe mental illness (SMI) worldwide. In rural China, the prevalence of physical illness comorbidity among persons with SMI remains unclear. This study aimed to examine non-communicable physical illness comorbidity and its risk factors among people with SMI in a rural area of China.A mental health survey, using the International Classification of Disease (ICD-10), was conducted in six townships of Xinjin District, Chengdu, China in 2015.A total of 724 persons with SMI were included in this study, and 37.8% of them had at least one physical illness. The most common physical illnesses were hypertension (10.5%) and diabetes (5.8%). More physical comorbidity was reported among persons with affective disorders than persons with schizophrenia. Many participants (37.4%) had never received antipsychotic treatment, and of those, 51.6% reported having a physical illness comorbidity. Significant associations were found between physical illness comorbidity and participants' family economic status, family size, age at onset of mental disorder, treatment status, and symptom severity.Our findings indicate the need of an integration of medical and psychiatric care in primary care. It also suggests that poverty and having never received treatment for mental health problems negatively affect the health of persons with SMI, which deserve more attention. Researchers and policymakers can take these findings into account to develop health policies and improve the mental and physical health care in rural China.

A sequence $(x_n)_{n=1}^{\infty}$ on the torus $\mathbb{T}$ exhibits Poissonian pair correlation if for all $s\geq0$, \begin{equation*} \lim_{N\to\infty} \frac{1}{N}\#\left\{1\leq m\neq n \leq N : |x_m-x_n| \leq \frac{s}{N}\right\} = 2s. \end{equation*} It is known that this condition implies equidistribution of $(x_n)$. We generalize this result to four-fold differences: if for all $s> 0$ we have \begin{equation*} \lim_{N\to\infty} \frac{1}{N^2}\#\left\{\substack{1\leq m,n,k,l\leq N\\\{m,n\}\neq\{k,l\}} : |x_m+x_n-x_k-x_l| \leq \frac{s}{N^2}\right\} = 2s \end{equation*} then $(x_n)_{n=1}^{\infty}$ is equidistributed. This notion generalizes to higher orders, and for any $k$ we show that a sequence exhibiting $2k$-fold Poissonian correlation is equidistributed. In the course of this investigation we obtain a discrepancy bound for a sequence in terms of its closeness to $2k$-fold Poissonian correlation. This result refines earlier bounds of Grepstad & Larcher and Steinerberger in the case of pair correlation, and resolves an open question of Steinerberger., 15 pages, to appear in Journal of Number Theory

Objectives: Understanding the scope of the current opioid epidemic requires accurate counts of the number of opioid-involved drug overdose deaths. Given known errors and limitations in the reporting of these deaths, several studies have used statistical methods to develop estimates of the true number of opioid-involved overdose deaths. This study validates these procedures using a detailed county-level database of linked toxicology and vital records data. Methods: We extracted and linked toxicology and vital records data from Marion County, Indiana (Indianapolis), during a 6-year period (2011-2016). Using toxicology data as a criterion measure, we tested the validity of multiple imputation procedures, including the Ruhm regression-based imputation approach for correcting the number of opioid-involved overdose deaths. Results: Estimates deviated from true opioid-involved overdose deaths by 3% and increased in accuracy during the study period (2011-2016). For example, in 2016, 231 opioid-involved overdose deaths were noted in the toxicology data, whereas the corresponding imputed estimate was 233 opioid-involved overdose deaths. A simple imputation approach, based on the share of opioid-involved overdose deaths among all drug overdose deaths for which the death certificate specified ≥1 drug, deviated from true opioid-involved overdose deaths by ±5%. Conclusions: Commonly used imputation procedures produced estimates of the number of opioid-involved overdose deaths that are similar to the true number of opioid-involved overdose deaths obtained from toxicology data. Although future studies should examine whether these results extend beyond the geographic area covered in our data set, our findings support the continued use of these imputation procedures to quantify the extent of the opioid epidemic.

As part of formative studies to design a program of collaborative care for persons with psychosis, we explored personal experience and lay attributions of illness as well as treatment among persons who had recently received care at traditional and faith healers’ (TFHs) facilities in three cultural groups in Sub-Saharan Africa. A purposive sample of 85 individuals in Ibadan (Nigeria), Kumasi (Ghana), and Nairobi (Kenya) were interviewed. Data was inductively explored for themes and analysis was informed by the Framework Method. Across the three sites, illness experiences featured suffering and disability in different life domains. Predominant causal attribution was supernatural, even when biological causation was also acknowledged. Prayer and rituals, steeped in traditional spiritual beliefs, were prominent both in traditional faith healing settings as well as those of Christianity and Islam. Concurrent or consecutive use of TFHs and conventional medical services was common. TFHs provided services that appear to meet the therapeutic goals of their patients even when harmful treatment practices were employed. Cultural and linguistic differences did not obscure the commonality of a core set of beliefs and practices across these three groups. This similarity of core worldviews across diverse cultural settings means that a collaborative approach designed in one cultural group would, with adaptations to reflect differences in context, be applicable in another cultural group. Studies of patients’ experience of illness and care are useful in designing and implementing collaborations between biomedical and TFH services as a way of scaling up services and improving the outcome of psychosis.

Our objective was to evaluate racial treatment and survival disparities in black women with ovarian cancer in the Deep South and to determine how environmental factors / socioeconomic status (SES) influence survival.A retrospective study of ovarian cancer patients from 2007 to 2014 was performed. Socioeconomic status (SES) was obtained though U.S. Census block data and compared using Yost scores. Comparisons were performed using standard statistical approaches.A total of 393 patients were evaluated, 325 (83%) white and 68 (17%) black. Demographic information and surgical approach were similar in each racial group. However, compared to whites, black patients had lower rates of optimal debulking [89% vs. 71%, respectively (p=0.001)] and intraperitoneal chemotherapy (19% vs. 11%, p=0.01). Black women had lower SES parameters including education, income, and poverty. As a result, more black patients had the lowest SES (SES-1) when compared to white patients (17% vs. 41%, p0.001). When controlling for these factors by cox regression analysis, a survival disadvantage was seen in black women for both progression free survival (16 vs. 27months, p=0.003) and overall survival (42 vs. 88months, p0.001).Despite controlling for clinical and environmental factors, a survival disadvantage was still observed in black patients with ovarian cancer in the Deep South. Black women had lower optimal debulking rates and more platinum resistant disease. These data suggest other factors like tumor biology may play a role in racial survival differences, however, more research is needed to determine this causation.

People’s lived experience of mental illness often includes symptoms associated with several different conditions. The Brief Symptom Inventory (BSI) is a well validated tool for collecting symptom self-reports that covers nine dimensions: depression, anxiety, phobia, paranoia, psychosis, OCD, hostility, somatisation, and interpersonal. In this paper, we investigate to what extent these dimensions are reflected in prosody. Prosody was characterised using five core principal components (PC) derived from GeMAPS analysis of a data set from 8 studies (14907 sound files, 990 participants). We used the data from a subset of 317 participants (5967 sound files, 4 studies) who had completed the BSI. Each BSI dimension shows a distinct pattern of correlations between the number of symptoms reported and our five PCs, but these patterns differwhen comparing undergraduates (more Caucasians, more females) and a patient sample (more African-Americans, more males). We conclude that speech corpora for mental health studies need better demographic balance.

This paper examines the effectiveness of command-and-control policies in the presence of incomplete and overlapping regulations. We study how recent bans on phosphate in household dishwasher detergent affect pollution loads to waterways, costs at wastewater treatment facilities, and consumer behavior. We show that the effectiveness of the bans in reducing effluent depends critically on regulations at receiving treatment facilities. As cost minimizers, facilities with an emissions standard on phosphorus face no incentive to deviate from the standard. We show that bans have weak effects on effluent, especially in the most polluted waterways. We also use an early, isolated ban in Spokane, Washington to study the effect of the bans on consumers. We find that this ban shifted approximately 40% of dishwasher detergent sales from Spokane to bordering counties until a state-wide ban was implemented. Using these estimates, we find that the welfare loss to consumers from recent bans is likely greater than the cost-savings to treatment plants.

Stigma associated with schizophrenia significantly affects family caregivers, yet few studies have examined the nature and determinants of family stigma and its relationship to their knowledge about the condition. This paper describes the experiences and determinants of stigma reported by the primary caregivers of people living with schizophrenia (PLS) in India. The study used mixed methods and was nested in a randomised controlled trial of community care for people with schizophrenia. Between November 2009 and October 2010, data on caregiver stigma and functional outcomes were collected from a sample of 282 PLS–caregiver dyads. In addition, 36 in-depth-interviews were conducted with caregivers. Quantitative findings indicate that ‘high caregiver stigma’ was reported by a significant minority of caregivers (21%) and that many felt uncomfortable to disclose their family member's condition (45%). Caregiver stigma was independently associated with higher levels of positive symptoms of schizophrenia, higher levels of disability, younger PLS age, household education at secondary school level and research site. Knowledge about schizophrenia was not associated with caregiver stigma. Qualitative data illustrate the various ways in which stigma affected the lives of family caregivers and reveal relevant links between caregiver-stigma related themes (‘others finding out’, ‘negative reactions’ and ‘negative feelings and views about the self’) and other themes in the data. Findings highlight the need for interventions that address both the needs of PLS and their family caregivers. Qualitative data also illustrate the complexities surrounding the relationship between knowledge and stigma and suggest that providing ‘knowledge about schizophrenia’ may influence the process of stigmatisation in both positive and negative ways. We posit that educational interventions need to consider context-specific factors when choosing anti-stigma-messages to be conveyed. Our findings suggest that messages such as ‘recovery is possible’ and ‘no-one is to blame’ may be more helpful than focusing on bio-medical knowledge alone., Highlights • Experiences of being blamed and worries about marital prospects were salient. • Caregivers' and PLS' experiences of stigma were determined by similar factors. • Knowledge was linked to stigma in qualitative but not in quantitative analyses. • Context-specific messages rather than biomedical knowledge may help reduce stigma. • Family caregivers need access to emotional and social support in their own right.

This article focuses on the impact of learning spaces as well as collaborative technology, which affects library building and design. The article illustrates that learning spaces are an important component in the design of library buildings rather then a temporary trend. During each of our company's latest public library building projects, both librarians and architecture teams have recognized the need to support increases in learning activities. To bring more users to the public library, they recommended that the building needed increased seating to support training, education and in‐house cultural programming. The stories cited in this article suggest that there is a relationship between learning spaces and collaborative technology. Among librarians and library planners, learning spaces are seen as a unifying requirement for the expansion of library services. They recognize that the library's seating plan must include more learning spaces to support social networking, sharing and project base learning. ...

The goal of global mental health trials is to generate knowledge that can be implemented in the much messier ‘real world’. However, the effect of interventions in the real world may be different from, and most likely much smaller than, the effect sizes reported in trials. It is therefore essential that we evaluate their implementation and effect when they are ‘scaled-up’ as real programmes. The evaluation of scaled-up health programmes typically involves the use of multiple methods which are triangulated to address the key questions of the programme leaders or investigators. This chapter aims to describe what outcomes we might be interested in evaluating and the methods we might use to assess these outcomes, and presents selected case studies which demonstrate these methods in action.

Our understanding of psychotic disorders is largely based on studies conducted in North America, Europe and Australasia. Few methodologically robust and comparable studies have been carried out in other settings. INTREPID is a programme of research on psychoses in India, Nigeria, and Trinidad. As a platform for INTREPID, we sought to establish comprehensive systems for detecting representative samples of cases of psychosis by mapping and seeking to engage all professional and folk (traditional) providers and potential key informants in defined catchment areas.We used a combination of official sources, local knowledge of principal investigators, and snowballing techniques.The structure of the mental health systems in each catchment area was similar, but the content (i.e., type, extent, and nature) differed. Tunapuna-Piarco (Trinidad), for example, has the most comprehensive and accessible professional services. By contrast, Ibadan (Nigeria) has the most extensive folk (traditional) sector. We identified and engaged in our detection system-(a) all professional mental health services in each site (in- and outpatient services-Chengalpet, 6; Ibadan, 3; Trinidad, 5); (b) a wide range of folk providers (Chengalpet, 3 major healing sites; Ibadan, 19 healers; Trinidad: 12 healers); and c) a number of key informants, depending on need (Chengalpet, 361; Ibadan, 54; Trinidad, 1).Marked differences in mental health systems in each catchment area illustrate the necessity of developing tailored systems for the detection of representative samples of cases with untreated and first-episode psychosis as a basis for robust, comparative epidemiological studies.

Stigma contributes greatly to the burden of schizophrenia and is a major obstacle to recovery, yet, little is known about the subjective experiences of those directly affected in low and middle income countries. This paper aims to describe the experiences of stigma and discrimination of people living with schizophrenia (PLS) in three sites in India and to identify factors influencing negative discrimination. The study used mixed methods and was nested in a randomised controlled trial of community care for schizophrenia. Between November 2009 and October 2010, data on four aspects of stigma experienced by PLS and several clinical variables were collected from 282 PLS and 282 caregivers and analysed using multivariate regression. In addition, in-depth-interviews with PLS and caregivers (36 each) were carried out and analysed using thematic analysis. Quantitative findings indicate that experiences of negative discrimination were reported less commonly (42%) than more internalised forms of stigma experience such as a sense of alienation (79%) and significantly less often than in studies carried out elsewhere. Experiences of negative discrimination were independently predicted by higher levels of positive symptoms of schizophrenia, lower levels of negative symptoms of schizophrenia, higher caregiver knowledge about symptomatology, lower PLS age and not having a source of drinking water in the home. Qualitative findings illustrate the major impact of stigma on ‘what matters most’ in the lives of PLS and highlight three key domains influencing the themes of 'negative reactions' and ‘negative views and feelings about the self’, i.e., ‘others finding out’, ‘behaviours and manifestations of the illness’ and ‘reduced ability to meet role expectations’. Findings have implications for conceptualising and measuring stigma and add to the rationale for enhancing psycho-social interventions to support those facing discrimination. Findings also highlight the importance of addressing public stigma and achieving higher level social and political structural change., Highlights • Internalised experiences of stigma were reported more commonly than discrimination. • A range of negative reactions beyond ‘discrimination’ led to feelings of devaluation. • Negative discrimination was predicted by illness features, e.g., positive symptoms. • Negative reactions were also linked to reduced ability to meet role expectations. • What mattered most to PLS was to achieve role expectations in marriage and work.

From Nuremberg and the disasters of the postwar period the passage has been difficult, but the gains substantial.