Change in internalized stigma and social functioning among persons diagnosed with severe mental illness

Factors Influencing the Health Care Utilization Among People With Depression and/or Anxiety Symptoms

BACKGROUND

This analysis aimed to examine the factors predictive of service utilization among patients with anxiety and/or depression. Quick and appropriate treatment for anxiety and depression can reduce disease burden and improve social functioning. Currently, less than half of the population with comorbid anxiety and depression receives the recommended treatment.

AIMS

This analysis aims to identify factors predictive of utilizing mental health treatment for those with anxiety and/or depression by analyzing intrinsic, patient-centered factors.

METHODS

This study is a cross-sectional cohort analysis using National Health Interview Survey (NHIS) 2019 data. The sample size is 7,156 adults aged 18 to 64 with family incomes ≤100% of the federal poverty level. We used multivariate logistic regression analysis to identify factors predictive of care utilization in this population. Variables of interest include scores on Patient Health Questionnaire-8 (PHQ-8) and Generalized Anxiety Disorder-7 (GAD-7), service utilization, level of social functioning, having a usual source for care, and previous mental health care utilization. Additional covariates were age, gender, race, country of origin, education, marital status, and insurance coverage.

RESULTS

Twenty-one percent of respondents reported using mental health services. Factors predictive of care utilization were older age, female gender, limited social functioning, having a usual source of care, and insurance coverage.

CONCLUSION

There are significant barriers to receiving quick and appropriate care for anxiety and/or depression. Strategies should focus on reducing barriers for young adults, men, and the uninsured/underinsured. Strategies for integrating mental health services into primary care could increase the percentage of people with anxiety and/or depression who receive services.

A Systematic Review of the Effect of Stigmatization on Psychiatric Illness Outcomes

A significant proportion of individuals with psychiatric disorders face dual challenges such as managing the symptoms and disabilities of their conditions and enduring stigma arising from misconceptions about mental illness. This stigma denies them quality-of-life opportunities, such as access to satisfactory healthcare services, better employment, safer housing, and social affiliations. This systematic review aims to evaluate the effect of stigmatization on psychiatric illness outcomes, particularly its influence on treatment adherence, treatment-seeking behavior, and care outcomes. We conducted a systematic review of 39 studies published between 2010 and 2024, focusing on the effects of stigmatization on psychiatric illness outcomes. The review utilized robust methodology following Cochrane guidance and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including studies from 2010 to 2024 obtained from databases such as PubMed, Embase, Google Scholar, Web of Science, and SCOPUS. The quality of the included studies was assessed using the Appraisal Tool for Cross-Sectional Studies, with most studies rated as moderate to high quality. The findings indicate that stigma in psychiatric illness is closely associated with several factors, including illness duration (mean effect size = 0.42, p < 0.05), frequency of clinic visits (mean reduction = 2.3 visits/year), and diagnosis of psychotic disorders (OR = 1.78, 95% CI: 1.20-2.65). Stigma manifests through misinformation, prejudice, and discrimination, leading to significant barriers to accessing and adhering to psychiatric treatment, thereby worsening health outcomes. It leads to delays in accessing healthcare, poor adherence to medication and follow-up, and negative psychiatric health outcomes, including disempowerment, reduced self-efficacy, increased psychiatric symptoms, and decreased quality of life. Also, stigma extends to caregivers and healthcare professionals, complicating care delivery. This review highlights the need for effective interventions and strategies to address stigma, emphasizing the importance of educational interventions to mitigate the adverse effects of public stigma. Understanding the multifaceted nature of stigma is crucial for developing targeted approaches to improve psychiatric care outcomes and ensure better mental health services for individuals with mental illnesses.

A longitudinal study on the effects of social support on self-stigma, psychiatric symptoms, and personal and social functioning in community patients with severe mental illnesses in China

BACKGROUND

Few studies have examined whether social support contributes to better consequences among chronic patients with severe mental illnesses (SMI) in their community recovery stage and whether self-stigma would be a mechanism through which social support impacts psychiatric symptoms and personal and social functioning.

AIMS

This study aimed to examine prospective associations of social support with long-term self-stigma, psychiatric symptoms, and personal and social functioning, and to investigate whether self-stigma would mediate the associations of social support with psychiatric symptoms and personal and social functioning among patients with SMI.

METHODS

A total of 312 persons with SMI (schizophrenia and bipolar disorder) in their community recovery stage participated in the study. Social support, self-stigma, psychiatric symptoms, and personal and social functioning were evaluated at baseline. The follow-up assessment was conducted at 6 months with the baseline measures except for social support. Hierarchical linear regression and mediation analysis were performed.

RESULTS

The results showed that baseline social support predicted decreases in stigma (β = -.115, p = .029) and psychiatric symptoms (β = -.193, p < .001), and increases in personal and social functioning (β = .134, p = .008) over 6 months, after adjusting for relevant covariates. Stigma at 6 months partially mediated the association between baseline social support and 6-month psychiatric symptoms (indirect effect: β = -.043, CI [-0.074, -0.018]). Stigma and psychiatric symptoms at 6 months together mediated the association between baseline social support and 6-month personal and social functioning (indirect effect: β = .084, 95% CI [0.029, 0.143]).

CONCLUSION

It is necessary to provide comprehensive social support services and stigma reduction interventions at the community level to improve the prognosis of SMI.

Associations of internalized stigma with psychosocial functioning and quality of life in people with schizophrenia

BACKGROUND

Schizophrenia is associated with poor functional recovery. Internalized stigma is one of the factors related to the functioning of individuals with schizophrenia. We aimed to investigate whether internalized stigma was associated with subjective and objective recovery-related outcomes after controlling for neurocognition and other important confounders in individuals with schizophrenia.

METHOD

We assessed the socio demographic background, psychopathology, neurocognition, internalized stigma, psychosocial functioning, and quality of life of 86 patients who had schizophrenia. Correlation analyses and multiple linear regression were used to investigate the association of internalized stigma and other variables with recovery-related outcomes.

RESULTS

We found that the negative symptom scores of the Positive and Negative Syndrome Scale but not internalized stigma was associated with psychosocial functioning as measured by the Personal and Social Performance global score. In contrast, internalized stigma was associated with the Psychological, Social relationships, and Environment scores of the World Health Organization Quality of Life Scale Brief Version (WHOQOL-BREF). Depression was also associated with the Physical health, Psychological, and Social relationships sores of the WHOQOL-BREF.

CONCLUSIONS

While internalized stigma was associated with several domains of quality of life, it was not associated with clinician-rated psychosocial functioning. The effects of internalized stigma on the subjective and objective recovery-related outcomes of individuals with schizophrenia might be divergent.

Profiles of Psychological Strengths on Symptom Distress, Recovery, and Quality of Life Among Young Adults with a History of Adolescent Psychiatric Hospitalization

The current study surveyed 166 young adults (ages 20-35) with a history of adolescent psychiatric hospitalization to identify profiles of psychological strengths (self-determination, identity commitment, and low mental health self-stigma) and to examine their association with symptom distress, recovery, and quality of life in young adulthood. Over half of all participants (51%) reported a high quality of life, and over one-third (40%) were not experiencing clinically-significant psychiatric symptoms. k-means cluster analysis identified three distinct profiles: low psychological strengths, mixed, and high strengths. Multiple regression analyses indicated the high strengths profile was significantly associated with lower symptom distress, higher recovery, and higher quality of life after controlling for demographics, psychiatric history, treatment experience, and psychiatric interference in school and relationships during adolescence. Findings have implications for targeted support and services based on psychological profile, including family support, interventions to support medication management such as shared decision-making, and peer support.

Early Maladaptive Schemas and Self-Stigma in People with Physical Disabilities: The Role of Self-Compassion and Psychological Flexibility

Self-stigmatizing thoughts may be rooted in one's core beliefs, and in turn be associated with early maladaptive schemas (EMS). Psychological flexibility, an ability to distance and accept one's thoughts, is reported to diminish EMS's effect on well-being, while self-compassion, a mindful attitude towards one's suffering, often reduces self-stigma. The objective of this study was to examine associations between EMS, self-stigma, psychological flexibility and self-compassion in individuals with disabilities, as they are at higher risk of experiencing self-stigma. Participants were 238 persons with disabilities. The Self-Stigma Scale, Young's Schemas Questionnaire, the Self-Compassion Scale Short and the Acceptance and Action-II Questionnaire were used. Hierarchical regression and mediation analysis were used to establish (1) predictors and (2) potential mediators of self-stigma in people with disabilities. Hierarchical regression showed that EMS alone accounted for 39% of the variance explained by self-stigma, and with the addition of psychological flexibility-an additional 2% was explained. Parallel mediation analyses indicated that psychological flexibility partially mediated the relationship between EMS domains and self-stigma. It appears that psychological rigidity is related to self-stigma and should be addressed in treatment through evidence-based approaches such as Schema Therapy and Acceptance and Commitment Therapy to enhance individuals' healthy life patterns, flexibility and self-compassion.

Self-stigma in Serious Mental Illness: A Systematic Review of Frequency, Correlates, and Consequences

Self-stigma is associated with poor clinical and functional outcomes in Serious Mental Illness (SMI). There has been no review of self-stigma frequency and correlates in different cultural and geographic areas and SMI. The objectives of the present study were: (1) to review the frequency, correlates, and consequences of self-stigma in individuals with SMI; (2) to compare self-stigma in different geographical areas and to review its potential association with cultural factors; (3) to evaluate the strengths and limitations of the current body of evidence to guide future research. A systematic electronic database search (PubMed, Web of Science, PsycINFO, Scopus, and Ovid SP Cumulative Index to Nursing and Allied Health Literature [CINAHL]) following PRISMA guidelines, was conducted on the frequency, correlates, and consequences of self-stigma in SMI. Out of 272 articles, 80 (29.4%) reported on the frequency of self-stigma (n = 25 458), 241 (88.6%) on cross-sectional correlates of self-stigma and 41 (15.0%) on the longitudinal correlates and consequences of self-stigma. On average, 31.3% of SMI patients reported high self-stigma. The highest frequency was in South-East Asia (39.7%) and the Middle East (39%). Sociodemographic and illness-related predictors yielded mixed results. Perceived and experienced stigma-including from mental health providers-predicted self-stigma, which supports the need to develop anti-stigma campaigns and recovery-oriented practices. Increased transition to psychosis and poor clinical and functional outcomes are both associated with self-stigma. Psychiatric rehabilitation and recovery-oriented early interventions could reduce self-stigma and should be better integrated into public policy.

Support for the social-cognitive model of internalized stigma in serious mental illness

One prominent social-cognitive model of internalized stigma by Corrigan and his colleagues (2012; 2002) proposes that individuals are exposed to societal stereotypes about mental illness, at least tacitly agree with them, and may apply them to oneself, engendering harmful self-beliefs. There is limited empirical support for this model in serious mental illness. Moreover, it is not clearly established how internalized stigma and its associated factors impact recovery in this population. The current study uses structural equation modeling (SEM) to assess the social-cognitive model's goodness of fit in a sample of Veterans with serious mental illness (Veteran sample, n = 248), and then validates the model in a second and independent sample of individuals receiving community-based psychiatric rehabilitation services (community sample, n = 267). Participants completed the Self-Stigma of Mental Illness Scale (SSMIS; Corrigan et al., 2006) and measures of self-esteem, self-efficacy, and recovery attitudes. Consistent with Corrigan and colleagues' formulation of internalized stigma, SEM analyses showed a significant indirect pathway from stereotype awareness, to stereotype agreement, to application to self, to self-esteem decrement, to poorer recovery attitudes. Additionally, there was a significant direct effect from stereotype awareness to self-esteem. This study shows that individuals with serious mental illness experience psychological harm from stigma in two ways: (1) through perceived public prejudice and bias, and (2) through internalizing these negative messages. In particular, stigma harms individuals' self-esteem, which then reduces their recovery attitudes.

Self-stigma in psychotic disorders: Clinical, cognitive, and functional correlates in a diverse sample

Self-stigma in mental illness is linked to negative clinical and functional outcomes, but little is known about its correlates specifically in psychotic disorders. Here we investigated the role of clinical symptoms, cognition, and vocational status as correlates of self-stigma in 98 individuals with psychotic disorders (36 Black American, 32 White Hispanic, 11 White Non-Hispanic, 11 Asian American). A principal component analysis of the Internalized Stigma of Mental Illness scale yielded three components: Experiential Stigma, Stereotype Endorsement, and Stigma Resistance. Higher Experiential Stigma was associated with greater severity of affective symptoms and lower vocational status. Higher Stigma Resistance was associated with higher social and non-social cognition, and higher vocational status. Stereotype Endorsement did not significantly correlate with any predictor variable. Linear regression models showed that 13% of the variance in Experiential Stigma was explained by affective symptoms and vocational status, and 20% of the variance in Stigma Resistance was explained by non-social cognition and vocational status. These findings provide new information about the correlates of self-stigma in an ethnically and racially diverse psychotic disorder sample. Such information may lead to a better understanding of self-stigma mechanisms in this population.

An effective psychological intervention in reducing internalized stigma and improving recovery outcomes in people with severe mental illness

Internalized stigma reduces chances of clinical and subjective recovery in people with schizophrenia and other severe mental illness. To date, there is not enough evidence about an effective intervention to reduce internalized stigma that promotes clinical and subjective recovery in people with high internalized stigma and severe mental illness. The aim of this study was to evaluate the efficacy of a new psychological intervention named "Coping Internalized Stigma Program" (PAREI). An eight-session structured group-based integrative intervention was designed including psychoeducation, cognitive behavioural therapy, and mutual support. Fifty-four individuals with severe mental illness and a high level of internalized stigma were selected and randomly assigned to the PAREI intervention (n = 29) or to the control group (n = 25). The results of mixed ANOVAs revealed improvements in the PAREI group after treatment in the emotional dimension of internalized stigma, perceived legitimacy of discrimination, recovery expectations, and social functioning as compared to the control group. The results indicate that the PAREI represents a promising intervention tool to reduce internalized stigma, and to improve clinical and subjective recovery markers in people with severe mental illness and high internalized stigma.

Mental Health Self-Stigma of Syrian Refugees With Posttraumatic Stress Symptoms: Investigating Sociodemographic and Psychopathological Correlates

Background: The high prevalence of mental disorders related to posttraumatic stress among Syrian refugees is often in contrast with their low utilization of mental health care in the host countries. Mental health self-stigma, i.e., internalized stigma of having a mental disorder, could prevent individuals from seeking mental health care. Therefore, we aimed to provide evidence on different aspects of mental health self-stigmatization among adult Syrian refugees with posttraumatic stress symptoms residing in Germany. Moreover, we investigated associations with sociodemographic and psychopathological variables in order to identify those at higher risk of self-stigmatization. Material and Methods: Overall, 133 participants with mild to moderate posttraumatic stress symptoms were recruited in the metropolitan areas of Leipzig, Dresden and Halle, Germany, using a multimodal approach. Mental health self-stigma was assessed using the Self-Stigma of Mental Illness Scale - Short Form (SSMIS-SF), consisting of four subscales (Stereotype awareness, Stereotype agreement, Application to self , Harm to self-esteem), each scoring from 5 (low) to 45 (high) points. Linear regression analysis was used to test associations of sociodemographic and psychopathological variables with self-stigma subscales. Results: On average, self-stigma ratings ranged from 16.5 (SD = 6.6) points on Application to self to 28.3 (SD = 7.5) points on Stereotype awareness. Results showed higher scores on Application to self for individuals who were younger (t = 2.65, p = 0.009) and single (F = 5.70, p = 0.004). Regression analyses yielded statistically significant associations between having multiple comorbidities and a higher Application to self stigma (β = 0.18, p = 0.044), controlling for sociodemographic covariates. Discussion: Mental health self-stigma was increased among Syrian refugees in Germany. Correlates of increased self-stigma could inform efforts to improve access to mental health care among Syrian refugees with mental ill-health. Longitudinal studies following an intersectional approach by concurrently examining multiple forms of public and internalized stigma could provide helpful insights for developing tailored stigma reduction efforts in this context.

Factors associated with internalized stigma for Indonesian individuals diagnosed with schizophrenia in a community setting

WHAT IS KNOWN ON THE SUBJECT?: Internalized stigma in people diagnosed with mental illness has several negative outcomes; however, it remains unclear in an Indonesian context. The human rights of people diagnosed with mental illness in Indonesia have been routinely violated because of the existing stigma against mental illness and deficiencies in the country's mental healthcare services. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: To the best of our knowledge, this is the first study to examine the level of internalized stigma and related factors among Indonesians diagnosed with schizophrenia. Almost one-third of the subjects had moderate-to-severe levels of internalized stigma, among which discrimination was the strongest type. Specifically, younger and unemployed people with more psychotic symptoms had higher levels of internalized stigma. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The provision of adequate pharmacological and psychosocial treatments to help people manage their psychotic symptoms is extremely important to ameliorate stigma. Vocational rehabilitation and employment support for unemployed people may potentially reduce their internalized stigma and promote recovery. ABSTRACT: Introduction The human rights of people diagnosed with mental illness in Indonesia have been routinely violated because of societal stigma associated with mental illness and deficiencies in the country's mental healthcare services. Knowledge about internalized stigma among people diagnosed with schizophrenia in lower middle-income Muslim countries is also scarce. Aim To identify the level of internalized stigma and related factors among people diagnosed with schizophrenia in Indonesia. Method A cross-sectional survey was conducted with a purposive sample of 300 people diagnosed with schizophrenia from an urban Indonesian psychiatric hospital. Results Almost one-third of the subjects had moderate-to-severe levels of internalized stigma, among which discrimination was the strongest type. Younger age, unemployment status and having psychotic symptoms significantly increased the risk of internalized stigma when analysed in a multivariable ordinal logistic regression. Discussion The present study firstly identified the high levels of internalized stigma among Indonesian individuals diagnosed with schizophrenia. Implications for practice Mental health nurses are suggested to provide early anti-stigma illness management and family psychoeducation interventions to people diagnosed with schizophrenia and their family caregivers, helping them to develop an optimistic understanding about the concept of schizophrenia and mitigating the negative consequences of public and internalized stigma.

Understanding Identity Changes in Psychosis: A Systematic Review and Narrative Synthesis

BACKGROUND AND OBJECTIVE

Experiencing psychosis can be associated with changes in how people see themselves as individuals and in relation to others (ie, changes in their identity). However, identity changes receive little attention in treatment, possibly due to a lack of clarity or consensus around what identity change means in people with psychosis. We aimed to create a conceptual framework synthesizing how identity changes are understood in the psychosis literature.

METHODS

Electronic databases were searched up to April 2020. Studies about identity changes among people with psychotic disorders were analyzed using narrative synthesis by a collaborative review team, including researchers from different disciplines, clinicians, and people who have experienced psychosis.

RESULTS

Of 10 389 studies screened, 59 were eligible. Identity changes are understood in 5 ways as (1) characteristics of psychosis, (2) consequences of altered cognitive functioning, (3) consequences of internalized stigma, (4) consequences of lost roles and relationships, and (5) reflections of personal growth. These 5 understandings are not mutually exclusive. Across a heterogeneous literature, identity changes were mostly framed in terms of loss.

CONCLUSIONS

Our conceptual framework, comprising 5 understandings, highlights the complexity of studying identity changes and suggests important implications for practice and research. For clinicians, this framework can inform new therapeutic approaches where the experience and impact of identity changes are acknowledged and addressed as part of treatment. For researchers, the conceptual framework offers a way of locating their understandings of identity changes when undertaking research in this area.

The impact of illness identity on recovery from severe mental illness: A review of the evidence

The "Illness Identity" model proposed that self-stigma impacts hope and self-esteem and subsequently leads to a cascade of negative effects on outcomes related to recovery among people diagnosed with severe mental illnesses. The purpose of the present review is to take stock of research support for the model. The citation index SCOPUS was reviewed for all papers published in peer-reviewed journals in English between 2010 and 2019 citing one of the initial 3 articles discussing the model: 111 studies met inclusion criteria and were reviewed. The most frequently tested, and supported, aspects of the model were relationships between self-stigma and self-esteem, hope, psychiatric symptoms and social relationships. Least frequently studied areas were relationships with suicide, avoidant coping, treatment adherence and vocational functioning, although they were supported in the majority of studies. The "insight paradox" was also tested in a relatively small number of studies, with mixed results. Findings were robust to geographic location of study, method, and subpopulation studied. Findings indicate that a large body of research has tested, and largely supported, the various components of the Illness Identity model, although some components need further investigation and there is a need for more comprehensive tests of the model.

Correlates of internalized stigma levels in people with psychosis in the Czech Republic

BACKGROUND

Internalized stigma negatively affects lives and prognosis of individuals with psychosis.

AIM

This study aimed to identify correlates of internalized stigma among individuals with psychosis in a sample of community care users in the Czech Republic.

METHODS

A cross-sectional study was conducted among 133 community service users with psychosis. A shortened version of the Internalized Stigma of Mental Illness (ISMI-10) scale was used alongside the 5-level EQ-5D version (EQ-5D-5L), assessing health-related quality of life. Descriptive and linear regression analyses were performed in order to determine levels of internalized stigma and its correlates.

RESULTS

High levels of internalized stigma were reported in 25% of participants. Lower internalized stigma levels were associated with better self-reported health status and being married, and higher internalized stigma with a longer period of time since initial contact with psychiatric care.

CONCLUSION

Lower internalized stigma levels are associated with better self-reported health-related quality of life. In addition, clients having used psychiatric care for longer periods of time reported significantly higher internalized stigma levels. Therefore, authors suggest self-stigma reduction interventions based in a community setting with an emphasis on targeting clients with chronic psychosis.

Experiences of self-stigmatization and parenting in Chinese mothers with severe mental illness

Mental health stigma has serious ramifications on people with a severe mental illness (SMI). Stigma damages self-esteem, recovery outcomes, family relationships, socialization abilities, access to housing, and career prospects. The cultural tendencies of Chinese people have been shown to be associated with particularly high levels of stigmatization. These cultural tenets can result in high levels of self-stigma due to experiencing shame and a perceived need to keep mental illness a secret. Although there is a lack of existing evidence, it is possible that such experiences present unique challenges to Chinese mothers diagnosed with SMI when they parent their children. Therefore, this qualitative study explored the experiences of parenting and self-stigmatization of Chinese mothers with SMI. Individual semi-structured interviews were conducted with 15 mothers who were direct carers of their children aged under 18 and who were receiving community-based care in Hong Kong. Manual inductive thematic analysis was used to analyse the interview data. Three main themes related to self-stigmatization emerged from the interviews: (i) distancing and being distanced; (ii) doubting myself; and (iii) struggling for control. The experiences of self-stigmatization appeared to damage these mothers' self-efficacy, which may negatively affect their parenting self-esteem, tendency to seek professional help, and ability to manage their own mental health. Strategies to improve self-efficacy, including psychoeducation, and additional childcare support/resources are required for mothers with SMI so they can better manage and balance the demands of motherhood and their mental healthcare needs.

Self-stigma versus stigma resistance in schizophrenia: Associations with resilience, premorbid adjustment, and clinical symptoms

Self-stigma is regarded as a barrier to recovery from schizophrenia and the identification of factors protecting from its development may help identify vulnerable patients and subsequently, implement effective preventive and therapeutic interventions. Hence, this study aimed to assess whether resilience, premorbid adjustment, and psychopathology might differently impact self-stigma and stigma resistance among 54 regular attendees of a specialized outpatient clinic. There was no significant association between sociodemographic variables and self-stigma/stigma resistance, while resilience was negatively correlated with self-stigma and positively correlated with stigma resistance. In addition, we detected a negative correlation between self-stigma and both academic and social functioning during late adolescence. Most residual symptoms correlated with self-stigma, while no association was found between stigma resistance and psychopathology, except for depressed symptoms. These data provide evidence that future self-stigma reduction interventions may consider to focus on the improvement of resilience in order to promote schizophrenia patients' stigma resistance. In addition, the improvement of depressive symptoms as well as interventions focusing on the strengthening of social adjustment during the prodromal phase may be effective in preventing self-stigma.

Stability and mutual prospective relationships of stereotyped beliefs about mental illness, hope and depressive symptoms among people with schizophrenia spectrum disorders

Internalized stigma, hope and depressive symptoms are important variables in the recovery process of people with schizophrenia spectrum disorders, but little is known about their stability or relationship among each other over time. This study aims to unravel the longitudinal stability and relationships of these variables. 99 participants were included in this prospective study assessing internalized stigma, hope and depressive symptoms at baseline, with a first follow-up after three months and a second follow-up after six months. Multilevel models examined if the variables changed over time and a correlation coefficient was conducted to show their relationship to each other. Hope stayed stable over time, whereas internalized stigma and depressive symptoms significantly decreased over the study period. The correlation coefficient showed that internalized stigma and depressive symptoms influenced each other moderately over time. Thus, while hope was a stable construct over time, internalized stigma and depressive symptoms changed significantly and were correlated to each other positively. This implies that participants may adjust to their chronic condition over time, and recovery focused interventions should target both psychological dimensions at the same time.

Factors influencing the level of self-stigmatisation in people with mental illness

AIM

The aim of this study was to assess sociodemographic factors and factors connected with treatment of mental illness and to decide whether they can influence the level of self-stigma.

METHOD

Sociodemographic characteristics (age, gender, family status, level of employment, level of education) and characteristics related to illness and treatment (diagnosis, length of treatment, adherence to treatment) were gathered in a group of patients in stable mental condition, without acute symptoms of mental illness. Self-stigma was measured using the Self-stigma of Mental Illness Scale - short form (SSMIS-SF).

RESULTS

The sample included 197 patients: 99 patients in group 1 (G1) with psychosis and 98 in group 2 (G2) with anxious and affective disorders. The average age was 44.15 ± 12.91 years, the length of illness was 11.67 ± 9.21 years and 48% of patients were men. The total average SSMIS-SF score was 61.54 ± 23.34. We found no statistically significant difference in the total level of self-stigmatisation between these groups ( t(197) = 0.77; p = .441). The level of self-stigmatisation (total score of SSMIS-SF) in patients in G1 (psychosis) increased with the length of illness r(99) = .253; p = .011. Employment status seems to correlate with the level of self-stigmatisation ( F(3, 184) = 5.27; p = .002). Patients unemployed and on disability pension had higher levels of self-stigmatisation than patients working full-time. Patients who took medication regularly (full medical adherence) had lower scores of SSMIS-SF total scores in comparison with patients with lower compliance ( t(195) = 3.476; p = .001; Cohen's d = .25).

CONCLUSION

According to our results, with regard to the factors that were followed, self-stigmatisation correlates with the presence of employment (social inclusion), duration of illness in patients with psychosis and treatment adherence. We did not find a statistically significant influence of age, gender, marital status or clinical diagnosis on the level of self-stigma.

Prediction of self-stigma in early psychosis: 3-Year follow-up of the randomized-controlled trial on extended early intervention

BACKGROUND

Self-stigma represents a major barrier to recovery in people with psychotic disorders but is understudied in early illness stage. Longitudinal investigation of prediction for self-stigma is scarce and none is conducted in early psychosis. We aimed to prospectively examine baseline predictors of self-stigma in early psychosis patients in the context of a 3-year follow-up of a randomized-controlled trial (RCT) comparing 1-year extension of early intervention (EI) with step-down psychiatric care for first-episode psychosis (FEP).

METHOD

One hundred sixty Chinese patients were recruited from a specialized EI program for FEP in Hong Kong after they had completed this 2-year EI service, and underwent a 12-month RCT. Participants were followed up and reassessed 3years after inclusion to the trial. Comprehensive evaluation encompassing clinical, functional, subjective quality of life and treatment-related variables were conducted. Data analysis was based on 136 participants who completed self-stigma assessment at 3-year follow-up.

RESULTS

Fifty patients (36.8%) had moderate to high levels of self-stigma at 3-year follow-up. Multivariate regression analysis revealed that female gender, prior psychiatric hospitalization, longer duration of untreated psychosis and greater positive symptom severity at study intake independently predicted self-stigma at the end of 3-year study period.

CONCLUSION

Our results of more than one-third of early psychosis patients experienced significant self-stigma underscore the clinical needs for early identification and intervention of self-stigmatization in the initial years of psychotic illness. Further research is warranted to clarify prediction profile and longitudinal course of self-stigma in the early illness phase.

The influence of psychosocial factors in veteran adjustment to civilian life

AIM

Although most veterans have a successful transition to civilian life when they leave the military, some struggle to cope and adjust to the demands and challenges of civilian life. This study explores how a variety of psychosocial factors influence veteran adjustment to civilian life in Scotland, UK, and which of these factors predict a poor adjustment.

METHODS

One hundred and fifty-four veterans across Scotland completed a set of questionnaires that measured veteran adjustment difficulty, quality of life, mental health, stigma, self-stigma, attitude towards help-seeking, likelihood of help-seeking, experiential avoidance, reappraisal and suppression.

RESULTS

Veteran adjustment difficulty and quality of life were significantly correlated to a number of psychosocial factors. Mental health, experiential avoidance and cognitive reappraisal were found to be predictors of veteran adjustment difficulty, and experiential avoidance and cognitive reappraisal partially mediated the relationship between mental health and veteran adjustment, with experiential avoidance being the stronger mediator.

DISCUSSION

Our findings suggest that early assessment of experiential avoidance and cognitive reappraisal and the provision of relevant emotion regulation skills training could potentially reduce the veteran's need for more complex (and costly) psychological interventions in the future. Implications for veterans, as well as the services and professionals involved with veteran transition and health care are discussed.

Self-stigma and treatment effectiveness in patients with anxiety disorders - a mediation analysis

GOAL

The goal of this study was to explore the impact of self-stigma on the treatment outcomes in patients with anxiety disorders and to find possible mediators of this relationship.

METHOD

Two hundred and nine patients with anxiety disorders, who were hospitalized in a psychotherapeutic department, attended the study. The average age was 39.2±12.4 years; two-thirds were women. Most of the patients used a long-term medication. The participants underwent either cognitive behavioral therapy (CBT) or short psychodynamic therapy. The selection to the psychotherapy was not randomized. All individuals completed several scales - Beck Depression Inventory, the second edition (BDI-II), Beck Anxiety Inventory (BAI), Dissociative Experience Scale (DES), Sheehan Disability Scale (SDS), subjective Clinical Global Impression (subjCGI), and The Internalized Stigma of Mental Illness Scale (ISMI). A senior psychiatrist filled out the objective CGI (objCGI).

RESULTS

The patients significantly improved in the severity of anxiety (BAI), depression (BDI-II), and overall severity of the mental disorder (objCGI). The self-stigma predicted a lower change of the objCGI, but not a change of the anxiety and depressive symptoms severity. Anxiety, depressive symptoms, dissociation, and disability were assessed as possible mediators of the relationship between the self-stigma and the treatment change. None of them were significant.

CONCLUSION

Self-stigma lowers the effectiveness of the combined treatment of anxiety disorders. Future research should explore other possible mediators influencing this relationship.

Ontological security and connectivity provided by pets: a study in the self-management of the everyday lives of people diagnosed with a long-term mental health condition

BACKGROUND

Despite evidence that connecting people to relevant wellbeing-related resources brings therapeutic benefit, there is limited understanding, in the context of mental health recovery, of the potential value and contribution of pet ownership to personal support networks for self-management. This study aimed to explore the role of pets in the support and management activities in the personal networks of people with long-term mental health problems.

METHODS

Semi-structured interviews centred on 'ego' network mapping were conducted in two locations (in the North West and in the South of England) with 54 participants with a diagnosis of a long-term mental health problem. Interviews explored the day-to-day experience of living with a mental illness, informed by the notion of illness work undertaken by social network members within personal networks. Narratives were elicited that explored the relationship, value, utility and meaning of pets in the context of the provision of social support and management provided by other network members. Interviews were recorded, then transcribed verbatim before being analysed using a framework analysis.

RESULTS

The majority of pets were placed in the central, most valued circle of support within the network diagrams. Pets were implicated in relational work through the provision of secure and intimate relationships not available elsewhere. Pets constituted a valuable source of illness work in managing feelings through distraction from symptoms and upsetting experiences, and provided a form of encouragement for activity. Pets were of enhanced salience where relationships with other network members were limited or difficult. Despite these benefits, pets were unanimously neither considered nor incorporated into individual mental health care plans.

CONCLUSIONS

Drawing on a conceptual framework built on Corbin and Strauss's notion of illness 'work' and notions of a personal workforce of support undertaken within whole networks of individuals, this study contributes to our understanding of the role of pets in the daily management of long-term mental health problems. Pets should be considered a main rather than a marginal source of support in the management of long-term mental health problems, and this has implications for the planning and delivery of mental health services.

Individual and Neighborhood Predictors of Mental Illness Stigma in New York State

While studies indicate that stigmatizing attitudes persist in the general public, individual and neighborhood level factors that are associated with increased likelihood of holding stigmatizing attitudes have been seldom studied. This study examined the demographic and neighborhood correlates of stigmatizing attitudes among community members in New York State. Data were drawn from the Pulse of New York State Survey, a random-digit dial survey of 806 New York State residents. Variables studied included demographic information, the Attitudes Toward Mental Illness scale, and neighborhood disadvantage at the zip code level (using data on community characteristics from the 2000 and 2010 Census). Higher levels of completed education predicted less stigmatizing attitudes. Higher levels of neighborhood disadvantage predicted more stigmatizing attitudes with the 2000 Census, and obtained marginal significance within the 2010 Census. Political affiliation demonstrated the strongest relationship, with more conservative ideology predicting more stigmatizing attitudes. Results highlight the need to consider political affiliation and neighborhood disadvantage as target areas when planning interventions for reducing mental illness stigma.

Self-stigma and affiliate stigma in first-episode psychosis patients and their caregivers

PURPOSE

Stigma is a major factor causing delayed help-seeking and poor treatment adherence in patients with psychotic disorders. Previous research has mostly focused on chronic samples and the impact of culturally-relevant variables on both patients' and their caregivers' stigmatization is understudied. This study aimed to examine the relationships between various forms of stigma, "face concern", and clinical characteristics in a group of Chinese first-episode psychosis (FEP) patients and their caregivers.

METHODS

Forty-four Hong Kong Chinese aged 15-54 years presenting with FEP to psychiatric services and their caregivers were recruited. Assessments on self-stigma, affiliate stigma, perceived public stigma, "face concern", symptom severity and subjective quality of life (QoL) were conducted.

RESULTS

Self-stigma of FEP patients was correlated with perceived public stigma, "face concern", insight and psychological health of QoL. Multiple regression analysis revealed that perceived public stigma and "face concern" independently predicted self-stigma. Mediation analysis further suggested that "face concern" partially mediated the relationship between perceived public stigma and self-stigma. Caregivers' affiliate stigma was significantly associated with higher levels of stress, and symptoms of depression and anxiety. Affiliate stigma did not correlate with perceived public stigma and "face concern".

CONCLUSION

Our results indicate a critical role of perceived public stigma and fear of losing face in determining self-stigma in Chinese patients with FEP. Caregivers with greater degree of affiliate stigma experience increased stress and emotional distress. Our findings highlight the importance to examine culturally specific factors that may contribute to the development of self-stigma in first-episode populations of different ethnicities.

Therapeutic intervention for internalized stigma of severe mental illness: A systematic review and meta-analysis

OBJECTIVE

Internalized stigma can lead to pervasive negative effects among people with severe mental illness (SMI). Although prevalence of internalized stigma is high, there is a dearth of interventions and meanwhile a lack of evidence as to their effectiveness. This study aims at unraveling the existence of different therapeutic interventions and the effectiveness internalized stigma reduction in people with SMI via a systematic review and meta-analysis.

METHODS

Five electronic databases were searched. Studies were included if they (1) involved community or hospital based interventions on internalized stigma, (2) included participants who were given a diagnosis of SMI>50%, and (3) were empirical and quantitative in nature.

RESULTS

Fourteen articles were selected for extensive review and five for meta-analysis. Nine studies showed significant decrease in internalized stigma and two showed sustainable effects. Meta-analysis showed that there was a small to moderate significant effect in therapeutic interventions (SMD=-0.43; p=0.003). Among the intervention elements, four studies suggested a favorable effect of psychoeducation. Meta-analysis showed that there was small to moderate significant effect (SMD=-0.40; p=0.001).

CONCLUSION

Most internalized stigma reduction programs appear to be effective. This systematic review cannot make any recommendation on which intervention is more effective although psychoeducation seems most promising. More Randomized Controlled Trials (RCT) on particular intervention components using standard outcome measures are recommended in future studies.

Development and validation of the Self-Stigma Questionnaire (SSQ) for people with schizophrenia and its relation to social functioning

Self-stigma specifically in people with schizophrenia has been little studied. The aims of the present study were to validate a new instrument for the assessment of self-stigma (SSQ) and to assess the relationship between self-stigma and social functioning in people with schizophrenia. A sample of 76 people with schizophrenia was assessed at two moments in time with the SSQ, the PDD (stigma), two scales of social functioning (LSP, SFS), and a scale of general functioning (GAF). The results indicated that SSQ presented good psychometric properties, with Cronbach's alpha ranging between 0.75 and 0.901. The stability of the instrument was between 0.836 and 0.402. Three factors were found in the factor analysis (social discrimination, perceived capabilities, concealment of the disease), explaining 62.66% of the total variance. A relationship was found between self-stigma and social functioning in people with schizophrenia, especially in relation to social contact. In conclusion, the SSQ seems to be a valid and reliable questionnaire for the assessment of self-stigma in people with schizophrenia, and interventions should be designed to cope with self-stigma in order to improve the social functioning of people who suffer schizophrenia.

Longitudinal course of self-labeling, stigma stress and well-being among young people at risk of psychosis

Stigma may undermine the well-being of young people at risk of psychosis. We therefore measured self-labeling, stigma variables and well-being at baseline and again one year later among 77 at-risk participants. An increase in self-labeling during this period predicted heightened stigma stress after one year and a decrease in stigma stress predicted better well-being at follow-up, controlling for symptoms, psychiatric comorbidity and sociodemographic variables. Besides early intervention programmes, strategies are needed to reduce the public stigma associated with at-risk status and to support young people at risk to better cope with self-labeling and stigma stress.

Insight, positive and negative symptoms, hope, depression and self-stigma: a comprehensive model of mutual influences in schizophrenia spectrum disorders

Aims. Insight, positive and negative symptoms, hope, depression and self-stigma are relevant variables in schizophrenia spectrum disorders. So far, research on their mutual influences has been patchy. This study simultaneously tests the associations between these variables. Methods. A total of 284 people with schizophrenia spectrum disorders were assessed using the Schedule for the Assessment of Insight, Positive and Negative Syndrome Scale, Integrative Hope Scale, Centre for Epidemiological Studies Depression Scale and Internalized Stigma of Mental Illness scale. Path analysis was applied to test the hypothesized relationships between the variables. Results. Model support was excellent. Strong and mutual causal influences were confirmed between hope, depression and self-stigma. The model supported the assumption that insight diminishes hope and increases depression and self-stigma. While negative symptoms directly affected these three variables, reducing hope and increasing depression and self-stigma, positive symptoms did not. However, positive symptoms diminished self-stigma on a pathway via insight. Conclusions. This study provides a comprehensive synopsis of the relationships between six variables relevant for schizophrenia spectrum disorders. Research implications include the need to investigate determinants of consequences of insight, and the sequence of influences exerted by positive and negative symptoms. Clinical implications include the importance of interventions against self-stigma and of taking a contextualized approach to insight.

Stigma Scale for Receiving Psychological Help (SSRPH): An Examination Among Adolescent Girls

Stigma is one of the greatest obstacles to care and impedes recovery. The Stigma Scale for Receiving Professional Psychological Help (SSRPH), a measure of public stigma, has been used in young adults and has limited psychometric data in adolescents. This article reports the reliability and validity of the SSRPH in adolescent girls (N = 156, age = 13-17). Discriminant validity was supported, but concurrent validity was not. The confirmatory factor analysis revealed excellent model fit and serves as beginning evidence for construct validity. Cronbach's alpha for the SSRPH was .65. The SSRPH was stable over 8 weeks. Findings suggest that the SSRPH can serve as a foundation for further instrument development. Future studies may explore enhancing the reliability and validity of the SSRPH and use advanced analytic techniques to examine the overall global construct of stigma, the latent constructs of public and private stigma, and associations of individual items to these constructs.

Internalized Stigma of Mental Illness (ISMI) scale: a multinational review

The Internalized Stigma of Mental Illness (ISMI) scale is a 29-item questionnaire measuring self-stigma among persons with psychiatric disorders. It was developed with substantial consumer input and has been widely used, but its psychometric qualities have not been comprehensively evaluated across multiple versions. Here we review the 55 known versions, and provide the 47 available versions, including: Arabic, Armenian, Bengali, Bulgarian, Chinese (Mainland, Taiwan, Hong Kong), Croatian, Dutch, English (USA, South Africa), Estonian, Farsi, Finnish, French, German, Greek, Hebrew, Hindi, Japanese, Khmer, Korean, Lithuanian, Lugandan, Maltese, Polish, Portuguese (Portugal, Brazil), Romanian, Russian, Samoan, Slovenian, Spanish (Spain), Swahili, Swedish, Tongan, Turkish, Urdu, and Yoruba, and qualitative English and Swahili versions, as well as versions for depression, schizophrenia, substance abuse, eating disorders, epilepsy, inflammatory bowel disease, leprosy, smoking, parents and caregivers of people with mental illness, and ethnicity. The various versions show reliability and validity across a wide range of languages, cultures, and writing systems. The most commonly reported findings of studies using the ISMI are that internalized stigma correlates with higher depression, lower self esteem, and higher symptom severity. Initial studies of ways to reduce internalized stigma are promising and warrant further investigation.

Anticipated discrimination is related to symptom severity, functionality and quality of life in schizophrenia

The aim of this study is to evaluate a possible relationship between the level of anticipated discrimination with severity of symptoms and functionality. We included 103 patients with schizophrenia. Severity of symptoms was measured by PANSS and Calgary Depression Scale for Schizophrenia. Quality of life (QL) and functionality were measured by using QLS, PSP and Functional Remission of General Schizophrenia Scale (FROGS). Anticipated/experienced discrimination was evaluated with four selected items from Discrimination and Stigma Scale. First, variables related to each item were determined by using t-test and later the variables that have an independent contribution to anticipated discrimination subscale of DISC were evaluated with linear regression analysis. Results showed that those who stated that they felt the need to conceal their diagnosis more had shorter duration of illness, lower PANNS scores, higher scores on professional performance subscale of QLS, a lower number of suicide attempts and higher current employment rates. Participants who reported that they had been avoided or shunned more had higher depression scores. While patients with lower level of functionality tended to stop themselves more, patients with high level of functionality tended to conceal their diagnosis.