Stigma associated with mental health problems among young people in India: a systematic review of magnitude, manifestations and recommendations

Background Globally, 20% of young people experience mental disorders. In India, only 7.3% of its 365 million youth report such problems. Although public stigma associated with mental health problems particularly affects help-seeking among young people, the extent of stigma among young people in India is unknown. Describing and characterizing public stigma among young people will inform targeted interventions to address such stigma in India, and globally. Thus, we examined the magnitude and manifestations of public stigma, and synthesised evidence of recommendations to reduce mental-health-related stigma among young people in India. Method A systematic review and meta-analysis of observational studies was conducted. Nine electronic databases were searched and 30 studies (n = 6767) met inclusion criteria. Results Most studies (66%) focused on youth training to become health professionals. One-third of young people display poor knowledge of mental health problems and negative attitudes towards people with mental health problems and one in five had actual/intended stigmatizing behavior (I2>=95%). Young people are unable to recognize causes and symptoms of mental health problems and believe that recovery is unlikely. People with mental health problems are perceived as dangerous and irresponsible, likely due to misinformation and misunderstanding of mental health problems as being solely comprised of severe mental disorders (e.g. schizophrenia). However, psychiatric labels are not commonly used/understood. Conclusion Public education may use symptomatic vignettes (through relatable language and visuals) instead of psychiatric labels to improve young people’s understanding of the range of mental health problems. Recommended strategies to reduce public stigma include awareness campaigns integrated with educational institutions and content relevant to culture and age-appropriate social roles. Supplementary Information The online version contains supplementary material available at 10.1186/s12888-020-02937-x.


Background
Young people, including adolescents and young adults aged 10-24 years [1] are at a critical period in the prevention and treatment of mental health disorders. Globally, an estimated one in five young people experience a mental disorder [2]. Among adults with a mental disorder, 75% report first experiencing a mental disorder during this period [3]. Although public stigma universally prevents people who experience mental health problems (i.e. symptoms that are not sufficient to warrant a diagnosis of a mental disorder) and those with mental disorders from seeking counselling and treatment, [4,5] the extent and manifestations of such stigma varies across cultures [6,7]. Public stigma is defined as interrelated 'problems of knowledge (ignorance), problems of attitudes (prejudice), and problems of behaviour (discrimination)' [8]. In India too, public stigma is an important factor in the underreported prevalence of mental disorders, [9,10] with only 7.3% of young people in India reporting a mental disorder and fewer accessing treatment [9].
Mental-health-related public stigma negatively impacts help-seeking by young people to a larger extent than among adults [11][12][13][14][15]. Young people with mental health problems are more likely to experience greater social distance from the public [16]. Additionally, compared to adults, young people do not seek help for mental health problems due to characteristic fears about lack of confidentiality, peer pressure, a desire to be self-reliant, [17] and lack of knowledge to recognize mental health problems [18] or lack of awareness about mental-healthrelated services [4]. Unsurprisingly, adolescents in a study found it more difficult to disclose their mental health problems compared to young adults [19].
The level of mental-health-related stigma among young people in India remains unknown. Stigma research in the United States, Greece, and Japan [20][21][22] identifies social distance and discriminatory beliefs related to mental health problems and a systematic review found stigma of mental disorders associated with violence, unpredictability and disability in Latin America and the Caribbean [23]. With the largest young population in the world at 365 million, [24] and a large burden of untreated mental health problems, young people in India will likely face challenges in achieving their social and economic potential. In 2015-16, India's national mental health survey highlighted that data on such mental-health-related stigma were limited [9]. Reducing public stigma is an aim in India's national mental health policy, [25] and in April 2017, India passed a law protecting the right to equality and non-discrimination of people with mental illness [26]. Through a systematic review and meta-analysis, this study aims to estimate the magnitude or prevalence of mental-health-related public stigma among a sub-group of the Indian population, i.e. young people aged 10-24 years old belonging to the general population; identify common problems in knowledge, attitude and behaviours associated with mental health; and collate recommendations for reducing mental-health-related public stigma.

Eligibility criteria
Studies were included in this systematic review if they assessed public stigma associated with mental health problems among young people (aged 10-24 years) in India. Quantitative and qualitative studies were included if they examined any component of mental-healthrelated public stigma: knowledge of mental health; attitude towards people with mental health problems; and (intended or actual) behaviour towards people with mental health problems. Studies were excluded if they focused on stigma experienced by people with a diagnosed mental disorder and caregivers, or vulnerable groups at rehabilitation centres, schools for special needs, prisons or shelters, exposed to violence or in conflict zones. These studies were excluded as they involved specific groups for whom explanatory models, quality of life, anticipated or experienced stigma related to personal/lived experiences and previously accessing care or treatment from mental health providers, likely influence knowledge about mental health problems, and attitude and behaviour towards people with mental health problems. Theoretical or methodological studies and protocols for systematic reviews, media articles and social media, policy statements, book reviews, interviews, and lists of books were excluded. No restriction was placed on language of publication or publication date.

Information sources
Nine databases were searched (PubMed, ADOLEC, CINAHL+, PsycINFO, Scopus, Social policy and practise, Global Health, Web of Science and IndMED). The search was started in October 2014, and the last search in all databases was conducted in September 2018. Results were managed in EndNote X9 [27].
Methods and findings are reported according to the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines, see Supplementary material [28]. The search strategy is presented in Table 1.

Study selection
The first author conducted this search across all databases and reviewed all studies based on the eligibility criteria, by reading all titles; next, by reading selected abstracts; and lastly, by reading the full text and references. Wherever there was incomplete information to include a study, it was moved to the next stage. If two or more articles on the same target population were found, the sample sizes and method were compared to confirm that the population studies were the same, and the most relevant article pertaining to eligibility criteria mentioned above, was retained for analysis. In the event that it was unclear if an article met review inclusion criteria, the first author discussed the article with the senior author.

Data extraction
The framework for data extraction included the following study characteristics: year of publication, sample size, location, % females, participant age, independent variables, dependent/ outcome variables corresponding to knowledge, attitude and actual/ intended behaviour components of mental-health-related public stigma reported. We extracted data from all studies where authors self-identified that they measured knowledge, attitude and actual/ intended behaviour (components of public stigma). In addition, we reviewed abstracts followed by full-texts of studies found using our search strategy, and based on research question, individual measures and results corresponding to each public stigma component, data were extracted. Ultimately, a variety of measures were used to assess each of these stigma components. The risk of bias in included studies was assessed using the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies [29]. Qualitative narratives about knowledge, attitude and behaviour related gaps in public stigma and recommendations to reduce public stigma were collated from both qualitative and quantitative studies.

Summary measures
The principal measures used in the primary studies include percentages, means (standard deviation), differences between means, and levels of significance (pvalues).

Synthesis and reporting
First, demographic information of participants was extracted from all survey studies as per review objectives. Second, heterogeneity across studies assessed through I 2 values determined if a meta-analysis of public stigma levels was appropriate. Similar to studies on prevalence of mental-health-related public stigma from Greece [21] and the United States, [20] we calculated such prevalence among youth. Public stigma levels were plotted by pooling study-wise percentage data on agreement with key statements related to knowledge, attitude and behaviour. If Standard Error (SE) was not reported by a study, the following formula was used: SE = ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi pð1 − pÞ p =n and 95%CI = p ± 1.96 X SE; where, p = percentage of participants agreeing with items/ statements displaying poor knowledge, negative attitudes and stigmatising actual or intended behaviours and CI = Confidence Interval. If a study reported multiple items corresponding to each public stigma component, then the item with the lowest (stigmatizing) percentage was included. For example, within the attitude domain of public stigma, if a study reported different percentages of participants who believed that persons with mental illness 'lack will power,' 'are to blame' and 'can't handle responsibilities,' then the lowest percentage was plotted. Review Manager software (Version 5.3.5) was used to conduct the meta-analysis [30]. Random-effects models were generated to calculate the pooled percentage of public stigma as studies were likely from different regions of India, with variations in population, subject selection methods and measures.
Third, a narrative synthesis [adapted from existing Economic and Social Research Council (ESRC) guidance] [31] as per study objectives was used to collate and group qualitative findings corresponding to common conceptual gaps and perceptions related to each public stigma component (knowledge, attitude or behaviour) and recommendations to reduce stigma. Gaps were presented in descending order of frequency (number of times a theme was repeated across multiple studies) and Table 1 Search strategy for studies of youth mental-health-related stigma in India

Category
Search terms Stigma (stigma or knowledge or awareness or myth or stereotyp a or attitude or prejudice or negativ a or discriminat a or exclusion or "social distance" or "intended behaviour" or avoid a or victim a or violen a or isolat a ) AND Mental health (mental OR psychiatr a OR psychol a OR anxiety OR panic OR bipolar OR "personality disorder" OR depression OR dissociative OR alcohol a OR dependency OR schizophreni a OR mania OR "learning disability" OR obsessive AND compulsive OR self AND harm OR self-harm OR paranoi a OR phobia a OR "post traumatic stress" OR insomnia a OR suicid a OR addicti a OR bereave a OR "attention deficit" OR body AND dysmorphic OR delirium OR delusion a OR hallucinat a OR hyperactiv a OR delinquen a OR aggress a OR "substance use" OR "substance abuse") AND India (India) a Symbol of truncation in order to search keywords with varying endings and plural forms importance (theme was included in the study discussion).

Results
Thirty studies were selected from 8872 articles in this review (Fig. 1). After removing 1040 duplicate articles, 7832 titles were screened based on the inclusion criteria. Next 291 abstracts were reviewed, of which 83 full-text studies were identified. One full-text article was unavailable [32].

Outcomes measured
One-third of all studies assessing mental-health-related stigma among youth reported on attitude [35, 37, 38, 45-48, 50, 52, 61]. Eight studies assessed knowledge related to mental illness, [33,39,40,53,56,58,59,62] seven studies assessed knowledge and attitude towards people with mental illness [41-43, 49, 54, 55, 60] and two studies focused on attitude and intended behaviour towards people with mental illness [36,51]. Only three studies assessed stigma comprehensively, across all components: knowledge, attitude and intended/actual behaviour [34,44,57]. As presented in the summary of study characteristics in Table 2, 16 out of 30 studies focused on stigma associated with mental illness (broadly defined, with no specific disorders included or excluded). The remaining studies were divided among epilepsy, phobia, suicide, and substance use (as specific disorders). Some of these studies included surveys with specific items/ scales measuring anxiety, panic disorder, bipolar disorder, depression, schizophrenia, and stress which are specific disorders/conditions. Stigma-related outcomes were measured using the Guttman social distance scale, [34,51] Attitude To Psychiatry-29 [42,45] and 30, [38] SUIATT questionnaire, [41] Opinions about Mental Illness, [42,60] Beliefs towards Mental Illness scale, [45] and the Attitude Scale for Mental Illness (ASMI) [34,51]. Other studies reported developing their own survey questionnaires. No study used a vignette-based survey to assess recognition of signs and symptoms of mental illness.

Synthesis of results
Meta-analysis of the prevalence of youth mental health stigma Percentage outcomes related to knowledge, attitude and actual/intended behaviour were pooled, as the studies were all among youth and reported similar study designs. Approximately 33% of youth participants in 16 pooled studies had poor knowledge (95% CI 25.88-39.71; p < 0.001), 36% in 12 pooled studies had negative attitudes (95% CI 28.74-44.18; p < 0.001) and 22% had stigmatising, actual or intended behaviours in four studies (95% CI 16.45-27.46; p < 0.001). However, this metaanalysis showed a high degree of heterogeneity, as the I 2 value ranges from 95 to 99% (Fig. 2).

Gaps in conceptualising mental illness
In order of frequency and importance across 21 included studies, Table 4 presents a summary of gaps corresponding to each stigma component: knowledge, attitude and behaviour.
Knowledge A significant majority of participants in some studies believed that people with a mental disorder can never recover [36,37,45]. One study suggests that in the Indian context, social distance was determined to a greater degree by lack of knowledge about recovery rather than perceived unpredictability or dangerousness [36]. Unsurprisingly, youth perceived that a battery of allopathic,      1. Was the research question or objective clearly stated?
Was the study population clearly specified and defined?     ayurvedic and homeopathic treatment was required to treat mental illness, [57] or that control over symptoms was possible only with prescription drugs [34] or hospitalisation [54]. Youth in other included studies believed that mental illness was principally due to genetic or supernatural causes, [34,44,57] or believed in myths that mental illness is infectious or due to a non-vegetarian diet [44]. Only one study from the capital city, Delhi found that environmental factors such as stress, biological factors and physical and sexual abuse, were perceived causes of mental illness among youth [34]. As a result, it is plausible that believing that factors outside of one's individual and social control are responsible for mental health problems may be linked to beliefs that  interventions to alleviate such problems are also beyond one's control. Further, although youth believed that it was easy to recognize people with mental illness when compared to people who suffer from other physical illnesses, [42,60] they were not able to correctly identify symptoms of mental health problems in any studies (including linking alcohol with only temporarily harmful effects) [49,[54][55][56].

Attitude
Negative perceptions that people living with mental illness are unable to control the problem, and are likely to be dangerous, violent, criminal or unpredictable was held by more than 70% of youth in four studies reporting these outcomes [44,45,52,60]. Beliefs that people with mental illness are cowards, [41] lack willpower, [49] are difficult to like [64] and are to blame for their problems [36,37] were found in several studies. Other studies found that people with mental illness were assumed to be less intelligent than others, [44,60] or be prone to changing their mind quickly [54]. In a study, suicide was perceived as a cowardly act by 70% of youth, 29% said it was impulsive and 36% said it was deliberate [41]. Talking about suicide was perceived to increase the risk of suicide [54] and since youth believed that people who are serious about suicide do not talk about it, [48] youth would likely find it difficult to communicate about such problems and brush aside disclosure of suicidal intent. In contrast, 89% of the students felt pity for an epileptic patient in one study [44]. A study showed that attitudes were most positive towards people with intellectual disability, and less favourable to people with acute mental illness, and least of all towards people who were associated with substance misuse [46]. Where substance use was involved, people with mental illness were labelled 'bad' and were expected to overcome their problem through will power [49]. The responsibility of work and social roles was deemed too difficult for people with mental illness by 41%, [52] 71% [50] and 63% [45] of youth in three studies. A study suggested that youth believed that people with mental illness could only be given work with minor responsibilities [45]. However, youth were divided between whether people with mental illness should get married and have children, as a form of treatment of their illness. In another study nursing students felt that mental illness was a strong ground for divorce compared to business management students, although business management students held significantly more stigmatising views than nursing students on whether people with mental illness should have children and hold a job [60]. Overall, studies show that youth were unaccepting of the autonomy and independence of theose suffering from mental illness and did not consider them capable of managing their personal and professional life.

Intended behaviour
Social distance [36] and stigmatisation [51] were likely behaviours of Indian youth towards people with mental health problems. Most youth in studies preferred to exclude people with mental health problems from treatment-related decision-making [50] and education [44]. In one study, between 25 and 40% of health professionals in-training believed that people with mental health problems need to be separated from others with physical illnesses for treatment [42]. Youth in a study would prefer to lock up or punish people with mental illness, out of fear of being attacked [42]. A third of business management students were significantly more likely to move out of a neighbourhood if a mental health facility was set up compared to nursing students [60]. About 48.5% of students in a study would not take a person suffering from a seizure to the hospital [44]. Unusual and shame-inducing practices, such as making the person smell a shoe or an onion, were associated with likely behaviours of youth towards a person going through an epileptic attack [44,57]. Youth in two studies preferred not to disclose mental illness, [41,60] with nearly 20% of youth in one study reporting that they would likely commit suicide if they developed a mental disorder [41]. However, in one study youth believed that feeding and keeping people with mental illness comfortable, equivalent to 'throwing money at the problem,' was not enough [42].

Recommendations to reduce youth mental health stigma in India Content and terminology
Most studies identify the need for interventions to sensitize students about potential causes, treatment effectiveness and duration, and abilities of people living with mental illness [33,34,44,46,50,55,57,60,62]. A study suggested that using lay language and commonplace perspectives on mental health and communitybased interventions may aid in reaching more youth [62]. Moreover, the use of bio-medical explanations and terms was found to intensify discriminatory attitudes [62,65]. Studies by Bell emphasize that the authors made assumptions that a common understanding of schizophrenia and severe depression exists, whereas participants may have understood survey instruments differently [37]. Finally, a study also hypothesized that emphasizing mental 'fitness' or wellbeing as a goal of mental health promotion may be more appealing and acceptable to youth [62].

Integrating with educational curriculum
Information campaigns targeting youth and the general public are emphasised as a key step towards reducing mental health stigma [44,45,49]. Public health awareness programs that use a broad, behaviour-focused approach were recommended to improve suicide and depression literacy [54]. As many studies in this review evaluate the level of stigma among health professionals in-training, enhancing educational curriculum, professional ethics and code of conduct, awareness camps and clinical training for improved treatment and care practise are advocated [38,42,45,52,57,61]. Some strategies to inculcate positive attitudes among medical and nursing students include: short educational interventions, [51] participation by consumers, [66] and use of role play and entertainment-education techniques [43]. In educational settings, recommended initiatives to reduce stigma include: continuous and repetitive educational efforts in partnership with parents and teachers, [44] reaching students who are not necessarily in direct contact with mental illness, [60] and lectures, media and wider campaigns about treatment of substance abuse [49]. Further, youth volunteering in activities or programs related to mental health may help them to build skills in mastering their environment [62].

Discussion
The most notable gap related to knowledge of mental health problems among young people in India was that all such problems were considered to be acute, severe or serious and therefore, people with such problems are perceived as dangerous or unable to manage their daily life or function as per societal roles and norms. Although US and Latin American youth perceive people with mental health problems as more dangerous if they associated these problems with genetic causes or biological reasons, [16,23] Indian youth lack knowledge about causes and largely associated such problems with functional impediments and believed that limited/no treatment exists for such problems. Next, young people in included studies were both unable to identify common symptoms or use a common term or psychiatric label to describe symptoms. Consequently, young people in India may not consider themselves vulnerable to acute problems or recognise every day mental health problems when they experience them. Similar to a crosssectional survey of public stigma among 15-60 year old Indians, [67] this review found that neither symptoms nor psychiatric labels nor mental illness (broadly) are widely recognized or understood. Since different expressions and thresholds for accepting symptoms of mental health problems may lead to such problems often going unnoticed [10,68] and since psychiatric labels may potentially induce prejudice (e.g. 'depressed' was self-rated as derogatory), [69] there is a need for culture-specific explanatory models of mental illness or use of culturallyappropriate vignettes instead of focusing on psychiatric labels to aid young people in recognizing mental health problems from an early age, in both stigma-assessment research questionnaires [70] and anti-stigma communication strategies [7,71,72].
Recommendations to reduce stigma by studies in this review include implementation of de-stigmatization and information-sharing interventions to build awareness and sensitize youth about mental health problems. Unlike, high income countries with national mental health education and promotion campaigns, such as the Time to Change campaign, [73] and Headspace, [74] India has no such country-wide mental health awareness campaign. Recent anti-stigma programmes involve university students in peer-led educational components as in the Active Minds and University Bring Change to Mind programmes [75,76]. A community-based anti-stigma campaign in India improved attitudes and intended behaviour towards people with mental health problems; however, it lacked a control group and targeted people above 18 years of age [77]. In the future, such interventions may be adapted to appeal to young people to address their age-appropriate needs and communication issues. Thus, future anti-stigma interventions should integrate with the education system, use interactive/ visual media and focus on mental health problems broadly, by defining and explaining symptoms through relevant vignettes or stories, rather than using psychiatric labels for specific disorders or illness.
This review shows that public stigma among youth in India has similar characteristics to public stigma in other cultures. Studies in this review show that Indian youth expressed fear, shame, sadness, pity or sympathy, similar to global attitudinal responses of 'stigmatisers.' [78] As in studies from Lebanon, [79] Singapore [13] and China, [80] evil spirits and God's punishment were important determinants of public stigma in India relative to environmental factors. Similar to adolescents in Greece, [81] Indian youth believed that mental health problems were easily identifiable and that people with such problems appeared markedly different. We also find that considerable youth believe in both traditional/faith healers and psychiatry as part of India's pluralistic medical system [82,83]. Additionally, our findings resonate with other studies that marriage and child-bearing are important life events, which represent social worth in Indian and Asian culture, [84][85][86] unlike in Western countries [7], but Indian cultures likely differ from the West in that autonomy, decision-making and capability of young people with mental health problems are overruled by adults. Further, culture may alter how participants perceive mental health problems, for example, alcohol consumption may not be perceived as harmful because of traditionally acceptable use of some addictive substances (e.g. betel nut) in India.
Potential factors that likely exacerbate stigma in India are that people in Asian cultures accept and observe status inequality more readily, [87] and youth seek to satisfy adults and echo the views of their families; a collectivist identity, where people fear what that others know about their problems [88] and gender inequality, since global studies report higher social distance among females than males [89][90][91]. Thus, despite the belief that Indian culture has protective, cohesive family environments which has the potential to readily accept those suffering from with mental health problems, [68] mental-health-related stigma persists. A study of 11 countries comparing how stigma operates in the East and West found that 'deep cultural concerns about how being diagnosed with a mental illness would impact family members,' social and economic status,' fear of disclosure and moral attributions affected stigmatizing attitudes in Eastern countries [92]. Such findings may also apply to youth in India and other low-and middle-income countries where there is a lack of understanding about stress and mental health issues, which then interact with other issues such as coping with poverty, in addition to strong cultural beliefs.

Strengths and limitations
This is the first systematic review to collate findings from mental -health -related stigma studies focused on youth in India. There are no other country-specific, youth-focused systematic reviews and meta-analyses on public stigma. The approach of assessing the magnitude of stigma and method developed are also unique to this review. This review outlines the evidence for an ageappropriate educational response to reducing public stigma in India, in three key ways: (i) quantifying the problem and the rationale for change; (ii) identifying and characterizing common gaps in knowledge, attitude and behaviour that require counter-messages; and (iii) synthesizing strategies to reduce public stigma. By applying the method used in this review, future studies may compare characteristics of youth stigmatization of people with mental health problems across countries and cultures. We believe that lectures, talks and discussions suggested by studies in this review may work for health professionals in-training, who develop stigma in a unique way, [93] however, alternative approaches will be required to engage students pursuing other disciplines who lack exposure to information about mental health problems and could have perhaps not previously encountered a person with a mental health problem. Such approaches must focus overtly on challenging stereotypes, by including more visual-based interaction and relatable language.
Although results of the meta-analysis present a worstcase scenario, selecting negative responses only, it highlights the magnitude of mental -health -related stigma and the need for intervention among youth in India. Potential reasons for high heterogeneity among pooled studies include varying definitions or terms, a range of assessment measures to gauge stigma and use of nonstandard data collection procedures. Given the limited number of studies providing adequate information on stigma, it was not feasible to assess whether stigma associated with particular disorders/conditions was similar to that of stigma associated with mental illness more generally or other disorders. As more than half of the included studies had a fair risk of bias and pooled data showed high heterogeneity, the review findings are unlikely to be valid among youth in other settings in India. Further, a lack of studies among school-going adolescents skew our results towards college youth and particularly, health professionals in-training. The quality of stigma-related studies may be improved in future cross-sectional studies through randomised sampling and sample size estimation, use of validated instruments and improved reporting. Due to lack of age-segregated data in community-based knowledge, attitude, behaviour-assessment studies, a comparison between the level of public stigma between Indian youth and adults was not feasible. As studies in this review were skewed by geography and population groups, it was not feasible to identify specific youth groups or regions which could be targeted to reduce public stigma. In addition, since most studies used survey instruments designed for adults, marriage and child-bearing find greater mention than education, employment, friendships or other youthrelevant milestones. Finally, one article was unavailable for inclusion in this systematic review.
To update this review with the most recent studies, we conducted the search strategy in PubMed and CINA HL+ (for the period September 2018-2020). Since 2018, we found six additional studies (including two that were previously unavailable), all of which support findings presented in this review. A quantitative study using a new scale found 18-24 year-old Indians' attitudes to suicide as negative, and that they felt suicide could not be prevented and that there were no risk signs [94]. Two other studies found poor levels of knowledge, with one study showing that 53.7% of students had poor knowledge regarding preventive measures of suicidal behaviour [95] and another showing that 43% of school students had inadequate knowledge of substance use [96]. Another study found that medical interns agreed that 'patients like this (with psychiatric illnesses) irritate me' or treating them was a 'waste of money.' [97] A qualitative study echoed our findings that mental health and mental illness were unclear concepts and were associated with acute problems, such as 'brain deficiency or dysfunction and abnormal behaviour.' [98] Another qualitative study found that college students believed that using substances helped to relieve depression, enhance health and lose weight and that using in small quantities did not cause harm [99]. The study suggests that future interventions should be non-judgemental, student-friendly, relatable and 'specific to the youth's life circumstances and needs.' Notably, updating the systematic review also highlighted several studies that contribute to the social context of mental-health-related stigma. A qualitative study of community stakeholder perspectives (not including youth) described that schools are hesitant to acknowledge the extent of mental health problems and students fear being labelled, thereby creating an environment of hiding mental health problems [100]. The study also highlighted the need for school and college counsellors and mental health training for teachers. Our review includes studies on nomophobia, an emerging mental health issue, which is echoed by contextual studies that finding increasing rates of substance use and technology addiction among youth due to urbanization in India [101]. Other studies focused on measuring prevalence, progression perceived harms of various disorders and conditions, including depression, anxiety and stress, [102,103] alcohol use, [104,105] body image disorders [106,107] and aggression, bullying and violence, [108] and correlates such as parental pressure to perform academically, [109,110], relationships, negative peer pressure, school environment and gender roles [110]. [111].

Conclusions
India is home to a third of the world's youth. Mental health problems are likely to adversely impact the productivity and capabilities of India's youth. Among youth included in this review, one-third had poor knowledge and negative attitudes, and one-fifth intended to or had actually discriminated against a person with mental illness. Although most of these studies were among college students, they were predominantly focused on health professionals in-training. A majority of youth potentially recognized mental health problems only if they were acute. Select aspects of traditional Indian culture, such as importance of marriage, are likely responsible for specific manifestations of stigma. Educational interventions to reduce stigma associated with mental health may improve help-seeking behaviours by avoiding the use of psychiatric labels that are not commonly understood, instead focus on symptomatic vignettes that may explicitly discuss a range of mental health problems with varying severity. Intervention content that directly and interactively discusses youth mental-health-stigma-related responses and age-appropriate social roles, rather than focusing on future roles such as marriage, may help to achieve timely detection of mental health disorders among youth.
Abbreviations PRISMA: Preferred reporting items for systematic reviews and meta-analyses; SE: Standard error; CI: Confidence interval; ESRC: Economic and social research council; K: Knowledge; A: Attitude; B: Behaviour