How stigma impacts on people with psychosis: The mediating effect of self-esteem and hopelessness on subjective recovery and psychotic experiences

The role of personal recovery and internalised stigma on the expression of symptomatology in severe mental disorders: Mediating and moderating effects

OBJECTIVE

Given the relevance of internalised stigma in people suffering from a mental disorder, in the present study, the possible mediating and moderating role of self-stigma in the relationship between personal recovery and symptomatology has been studied.

METHOD

265 participants with severe mental disorder completed the following instruments: ISMI (self-stigma), REE (personal recovery) and HoNOS, CGI, GAF and EuroQol (symptomatology).

RESULTS

both the mediation and moderation analyses show significant results, which would indicate that internalised stigma has an effect on the relationship between personal recovery and symptomatology. Also, people with lower level of personal recovery and greater self-stigma have greater symptomatology than those who are in more advanced personal recovery processes and have a lower perception of internalised stigma.

DISCUSSION

the findings of this study suggest that self-stigma has an effect, and the improvement at personal recovery and symptomatology is accentuated when people with a severe mental disorder have a better management of internalised stigma. Therefore, it may be interesting to include this variable in recovery interventions.

Integrating Subjective Recovery and Stigma Resistance in Individuals with Schizophrenia: A Narrative Review and Theoretical Integration

Stigmatised attitudes are known to be associated with negative outcomes in schizophrenia, yet there is little focus on the role of stigma in the recovery process. Attempts to develop interventions to reduce self-stigma in schizophrenia have not been found effective. This paper presents a theoretical integration based on a narrative review of the literature. PsycINFO, Medline and Embase databases were searched up to the 11th December 2023. Studies were included if they were: i) empirical studies using qualitative, quantitative or mixed methods studies investigating mental health stigma; ii) included participants based in the United Kingdom, fluent in English, between the ages of 16 and 70, meeting criteria for a schizophrenia spectrum diagnosis. Fourteen studies were included. In Part 1, we propose a novel theoretical model derived from a synthesis of service-user perspectives on the relationship between stigma and schizophrenia. Stigmatised attitudes were commonly perceived to be caused by a lack of education and further exacerbated by disinformation primarily through the media and cultural communities. Stigma led to negative self-perceptions, negative emotional responses, social isolation and increased symptom severity, ultimately acting as a barrier to recovery. In Part 2, we identify several factors that ameliorate the impact of stigma and promote clinical and subjective recovery among service-users: education, empowerment, self-efficacy, self-acceptance, hope and social support. We argue that the notion of stigma resistance may be helpful in developing new interventions aimed at promoting recovery in individuals with schizophrenia. Wider implications are discussed and recommendations for future research and practice are explored.

Self-stigma, religiosity, and perceived social support in people with recent-onset psychosis in the Islamic Republic of Iran: Associations with symptom severity and psychosocial functioning

AIMS

Most evidence on psychosocial factors in recent-onset psychosis comes from high-income countries in Europe, Australia, Canada and the USA, while these factors are likely to differ under varying sociocultural and economic circumstances. In this study, we aimed to investigate associations of self-stigma, religiosity and perceived social support with symptom severity and psychosocial functioning in an Iranian cohort of people with recent-onset psychosis (i.e. illness duration of <2 years).

METHODS

We used baseline data of 361 participants (N = 286 [74%] male, mean age = 34 years [Standard Deviation = 10.0]) from the Iranian Azeri Recent-onset Acute Phase Psychosis Survey (ARAS). We included assessments of self-stigma (Internalized Stigma of Mental Illness, ISMI), religiosity (based on Stark & Glock), perceived social support (Multidimensional Scale of Perceived Social Support, MSPSS), symptom severity (Positive And Negative Syndrome Scale, PANSS) and psychosocial functioning (clinician-rated Global Assessment of Functioning Scale, GAF, and self-reported World Health Organization Disability Assessment Schedule 2.0, WHODAS 2.0). Descriptive analyses were employed to characterize the study sample. Covariate-adjusted ordinal and multivariable linear regression analyses were performed to investigate cross-sectional associations of baseline ISMI, religiosity and MSPSS with concurrent PANSS, GAF and WHODAS 2.0.

RESULTS

Higher self-stigma was associated with poorer self-reported functioning (B = 0.375 [95% Confidence Interval (CI): 0.186, 0.564]) and more severe concurrent symptoms (B = 0.436 [95% CI: 0.275, 0.597]). Being more religious was associated with poorer clinician-rated functioning (OR = 0.967 [95% CI: 0.944, 0.991]), but with less severe symptoms (B = -0.258 [95% CI: -0.427, -0.088]). Stronger social support was associated with poorer clinician-rated (OR = 0.956 [95% CI: 0.935, 0.978]) and self-reported functioning (B = 0.337 [95% CI: 0.168, 0.507]).

CONCLUSION

This study shows that self-stigma, religiosity and perceived social support were associated with symptom severity and clinician-rated as well as self-reported psychosocial functioning in an Iranian cohort of people with recent-onset psychosis. The findings extend previous evidence on these psychosocial factors to one of the largest countries in the Middle East, and suggest that it may be worthwhile to develop strategies aimed at tackling stigma around psychosis and integrate the role of religiosity and social support in mental ill-health prevention and therapy.

Honest, Open, Proud (HOP) for people with mental illness in Hong Kong: a randomized controlled trial

BACKGROUND

Self-stigma among people with mental illness is negatively associated with personal and clinical recovery. Due to the concealable nature of mental illness, people with mental illness experience constant struggles between concealment and disclosure. Disclosure of mental health challenges can potentially minimize negative impacts of self-stigma and enhance self-esteem and sense of empowerment. Honest, Open, Proud (HOP) is a peer-led intervention that promotes autonomous and dignified decisions about disclosure.

PURPOSE

This study examined the effectiveness of HOP on concealment motivation, empowerment, self-stigma, stigma stress, and recovery among people with lived experience of mental illness in Hong Kong.

METHODOLOGY

A total of 162 participants with a mean age of 45.38 were recruited and randomized into intervention group and waitlist control group. Participants in the intervention group were invited to attend a 6-session HOP group intervention.

RESULTS

Significant improvement in optimism score from the empowerment scale was found in the intervention group compared to the waitlist control group and the effect was sustained at 1-month follow-up. However, significant changes were not found in other outcome variables.

CONCLUSION

Only improvement in optimism was observed in the current study. Future study needs to examine the effects of HOP with further modification to maximize the benefit for people with lived experience of mental illness in the local context.

Subjective quality of life and schizophrenia: results from a large cohort study based in Chinese primary care

INTRODUCTION

Much confusion exists between health-related QoL (HRQoL) scales and subjective QoL (SQoL) scales. One method to avoid confusion is use of a single question that asks What is your quality of life? or similar. This study explored the relationship between biopsychosocial factors and high SQoL, SQoL stability, and factors associated with improving SQoL.

METHOD

We conducted a large cohort study of community-dwelling Chinese adults with schizophrenia, with two data points (2015-2016 (N = 742), 2017-2018 (N = 491)). Demographic and clinically related items and a comprehensive suite of published measures were collected. Direct logistic regressions were used to explore links between biopsychosocial factors and high SQoL and Improvement in SQoL across time.

RESULTS

Sample at Baseline: Male = 62.3%; Med age = 38.5 years; Med Age at illness onset = 24 years; SQoL Mode = neither poor nor good. Three independent variables predicted high SQoL at T1. Contemporary age and the presence of clinically relevant symptoms had a negative relationship with high SQoL; insight had a positive relationship with high SQoL. SQoL changed significantly across time with a modest effect size. Age at illness onset was the single independent variable linked to improving SQoL favoring being older at the time of illness onset.

DISCUSSION/CONCLUSIONS

SQoL can be high and changeable. While symptomology and illness insight may affect SQoL self-appraisals at single points in time, only age of illness onset was connected with improving SQoL. Thus, public health measures to delay illness onset are important. In addition, care about the distinction between HRQoL and SQoL in study design and choice of measures is necessary and will depend on the purpose and context.

Social identification, identity integration and wellbeing in people who hear voices

OBJECTIVES

Hearing voices is associated with public stigma and this can influence readiness to identify as a voice hearer (VH) and psychological wellbeing. In this study, we investigated the relationships between a VH social identity, the integration of that identity with other important social identities and wellbeing.

DESIGN

Cross-sectional study, with a subset of longitudinal data across three time points.

METHODS

People who self-identified as voice hearers completed questionnaires (VH social identity, identity integration, wellbeing and perceptions of in-group and out-group empathy) at three time points, spaced at 3-monthly intervals. The final sample comprised 182 participants at T1, 91 at T2 and 75 at T3. Hierarchical linear multiple regression analyses were used to test all hypotheses.

RESULTS

The integration of a VH social identity was strongly associated with better psychological wellbeing at T1. Identity integration was also associated with static wellbeing scores at 6 months. Effects on wellbeing were not accounted for by either severity of voice-hearing or paranoia. Whilst perceptions of in-group empathy were associated with VH social identification, perceptions of outgroup empathy were important for identity integration.

CONCLUSIONS

Integrating a VH social identity with other important identities into a coherent sense of self is important for wellbeing in voice hearers; perceived in-group and outgroup empathy are important in this process.

Defining recovery in schizophrenia: A review of outcome studies

Schizophrenia is a chronic disorder with a heterogenous course and different ways in which recovery is measured or perceived. Recovery in schizophrenia is a complex process that it can be defined either from a clinical perspective focused on sustained symptom and functional remission, or from a patient-focused one, as a self-broadening process aimed at living a meaningful life beyond mental illness. Until now, studies analysed these domains separately, without examining their mutual relations and changes over time. Therefore, this meta-analysis aimed to examine the relationship of global measures of subjective recovery with each of the components of clinical recovery such as symptom severity and functioning, in patients with schizophrenia spectrum disorders. The results showed that the association between different indicators of personal recovery and remission are weak and inverse (^dIG⁺ = -0.18, z = -2.71, p < 0.01), however, this finding is not substantial according to the sensitivity indicators. With respect to functionality and personal recovery, there was a moderate relationship (^dIG⁺ = 0.26, z = 7.894, p < 0.01) with adequate sensitivity indices. In addition, a low consensus exists between subjective measures that are more related to the patient's perspective and clinical measures based on experts and clinician's viewpoint.

Effect of a group-based acceptance and commitment therapy (ACT) intervention on self-esteem and psychological flexibility in patients with schizophrenia in remission

The present study explored whether acceptance and commitment therapy (ACT), a cognitive behavioral therapy approach, could improve the symptoms of schizophrenia spectrum disorders among patients with schizophrenia in remission. A pre- and post-treatment design with two evaluation time points was employed. Sixty outpatients with schizophrenia in remission were randomly divided into two groups: the ACT plus treatment as usual (ACT+TAU) and treatment as usual (TAU) groups. The ACT+TAU group participated in 10 group-based ACT interventions and TAU in the hospital, and the TAU group only received TAU interventions. General psycho-pathological symptoms, self-esteem, and psychological flexibility were assessed before intervention (baseline; pre-test) and after intervention (five weeks; post-test). Results indicated that, compared to the TAU group, the ACT+TAU group exhibited a more significant improvement in general psychopathological symptoms, self-esteem, cognitive fusion, and acceptance and action at post-test. ACT intervention could effectively decrease the general psycho-pathological symptoms and increase self-esteem level and psychological flexibility in people with schizophrenia in remission.

A 20-year review comparing the use of 'schizophrenia' and 'psychosis' in UK newspapers from 2000 to 2019: Implications for stigma reduction

BACKGROUND

There have been increasing calls for schizophrenia to be renamed to reduce negative associations with the diagnosis. 'Psychosis' is one proposed alternative, yet some research suggests this has greater negative connotations. This study compared the use of both terms within UK newspapers longitudinally to assess which is more negatively portrayed in the media.

STUDY DESIGN

Using LexisLibrary News, six UK newspaper archives were searched for the terms 'schizophrenia' and 'psychosis' in articles published between 2000 and 2019; the included article total was n = 9802. Articles were analysed using Linguistic Inquiry and Word Count software.

STUDY RESULTS

A two-level multilevel model was created of newspaper articles nested within newspapers. Adding predictors revealed that diagnostic term was a significant predictor of the emotional tone of articles (β = -2.30, SE = 0.51, p < .001, 95 % CI -3.30 to -1.30), with 'psychosis' having a more negative tone than 'schizophrenia.' Tabloids were shown to have a significantly more negative tone than broadsheets (β = -9.32, SE = 1.04, p < .001, 95 % CI -11.36 to -7.28), and emotional tone of writing had become more negative over time (β = -0.26, SE = 0.04, p < .001, 95 % CI -0.34 to -0.18).

CONCLUSIONS

These findings suggest 'psychosis' is associated with greater negativity than 'schizophrenia' within UK newspapers, and may be a poor substitute term to reduce stigma. As article tone worsened for both diagnoses over time, increased stigma reduction campaigns are required to target negativity within the media.

Predictors of Internalized Stigma in Patients with Schizophrenia in Northern Chile: A Longitudinal Study

The study aim was to longitudinally assess internalized stigma in a sample of patients from Northern Chile with a diagnosis of schizophrenia along with indicators of patient recovery, including quality of life, psychotic symptomatology, social cognition, premorbid adjustment, and years of untreated psychosis. The 10-year follow-up of stigma measures and predictors were assessed at public outpatient mental health centers in the city of Arica, Chile, during the months of March–July 2012. A total of 26 patients successfully completed the evaluation. The results revealed that, with the exception of the self-stigma subdimension, no clinically significant changes were seen in the trajectories of internalized stigma ratings between baseline and 10-year follow-up, underscoring the importance of assessing global components such as quality of life and premorbid adjustment during the process of internalizing stigma.

Correlates and predictors of perceived stigma and self-stigma in Chinese patients with psychosis

AIMS

In patients with psychosis, perceived stigma (i.e., beliefs about discriminative viewpoints held by the public) and self-stigma (i.e., internalization of such perceived stereotypes) could have devastating consequences. Knowledge about their correlates bears importance for understanding individual differences in stigma experiences, and further, given the social nature of stigma, Asians may show more distinctive features than Westerners.

METHODS

A total of 142 Chinese patients who originally enrolled into a randomized controlled trial during their first-episode psychosis were followed up at 10 years. We explored potential demographics, clinical and psychosocial correlates of perceived stigma and self-stigma.

RESULTS

Stepwise multiple regression analyses indicated that both perceived- and self-stigma were predicted by a more negative attitude to treatment, whereas differential factors including perceived recovery predicted perceived stigma, and quality of life and attention predicted self-stigma.

CONCLUSIONS

These results can help identify individuals susceptible to experiencing perceived- or self-stigma, highlighting the need to consider factors such as attitude towards treatment when designing anti-stigma strategies.

An investigation of internalized stigma and recovery levels of patients registered in a Community Mental Health Center

AIM

This study was carried out to investigate the internalized stigma and recovery levels of patients registered in a Community Mental Health Center (CMHC).

MATERIAL AND METHODS

This descriptive study was completed with 230 psychiatric patients to a registered Community Mental Health Center is located in Turkey. Data were collected using a sociodemographic characteristics' form, the Internalized Stigma of Mental Illness Scale (ISMI), and the Maryland Assessment of Recovery in Serious Mental Illness (MARS).

RESULTS

A statistically significant negative relationship was found between total ISMI and MARS scores (p < 0.05).

CONCLUSION

The internalized stigma and recovery levels of individuals diagnosed with mental illness registered at the CMHC were found to be normal.

The relationship between clinical recovery and personal recovery among people living with schizophrenia: A serial mediation model and the role of disability and quality of life

OBJECTIVE

We examine the relationship between two perspectives on recovery from schizophrenia: clinical recovery and personal recovery. Clinical recovery emphasizes an individual's psychiatric symptoms and functioning, whereas personal recovery emphasizes adaptation to one's illness that includes taking responsibility for one's recovery, establishing an identity apart from the illness, and finding meaning, purpose, and hope in life.

METHODS

Using serial mediation analysis, we examine the relationship between clinical and personal recovery in the context of two potential mediators, disability and quality of life. Study participants were 356 people with a diagnosis of schizophrenia and living with family in Changsha City of Hunan Province, China.

RESULTS

Although clinical recovery was modestly associated with personal recovery (r = 0.27, p < 0.001), subsequent serial mediation analysis showed that clinical recovery is not directly related to personal recovery when accounting for disability and quality of life. Clinical recovery was a significant predictor of disability, which predicted quality of life and personal recovery. Among the three mediation paths, quality of life accounted for most of the mediation effect (54%), followed by disability (24%), and disability and quality of life serially (22%). We discuss the implications of these findings for theory development, intervention, and future research.

Across the continuum: Associations between (fluctuations in) momentary self-esteem and psychotic experiences

OBJECTIVE

Low self-esteem has been suggested as a putative mechanism in the development and maintenance of psychosis. Uncertainty still exists about how unstable self-esteem relates to psychotic experiences. The present study examines the potential (temporal) associations between momentary self-esteem, fluctuations in self-esteem, and psychotic experiences in daily life.

METHODS

Experience sampling data were collected from 46 individuals presenting with an at-risk mental state (ARMS), 51 individuals with first-episode psychosis (FEP), and 53 controls, to investigate associations between (fluctuations in) self-esteem and psychotic experiences within and across FEP, ARMS, and controls, using linear mixed models.

RESULTS

In all three groups we found that lower momentary self-esteem was associated with a greater intensity of psychotic experiences (adj. β_FEP = -0.15, 95% CI -0.20 to -0.10, p = 0.000; adj. β_ARMS = -0.20, 95% CI -0.26 to -0.15, p = 0.000; adj. β_controls = -0.12, 95% CI -0.17 to -0.07, p = 0.000). Variability in momentary self-esteem was associated with a greater intensity of psychotic experiences only in ARMS (adj. β_ARMS = 0.08, 95% CI 0.04 to 0.11, p = 0.000) and controls (adj. β_controls = 0.04, 95% CI 0.01 to 0.08, p = 0.023). For instability this association held only in controls (adj. β_controls = 0.03, 95% CI 0.00 to 0.05, p = 0.020). Furthermore, findings may suggest a reciprocal temporal association between self-esteem and psychotic experiences.

CONCLUSIONS

Our findings suggest that self-esteem may be an important mechanism targetable by ecological momentary interventions to reduce the intensity of psychotic experiences and potentially prevent illness progression at an early stage.

Experiences of Hospitalization of Patients With Psychotic Disorders on Medical-Surgical Units: A Thematic Analysis

BACKGROUND:Individuals with psychotic disorders are more likely to have nonpsychiatric hospitalizations than the general population. Moreover, they experience worse outcomes in terms of rehospitalization, adverse events, in-hospital mortality, and longer length of stay. AIM: A patient-centered understanding of inpatient medical-surgical hospitalization experiences could shed light on disparities in hospital outcomes among individuals with psychotic disorders. METHOD: This article reports findings from Phase 1 (Qualitative) of a mixed methods, exploratory sequential study of nonpsychiatric hospitalizations of patients with psychotic disorders. Patients on medical-surgical units with diagnosed psychotic disorders (n = 20) were interviewed about their experiences of hospitalization, and a thematic analysis was conducted of transcripts, case notes, and setting notes. RESULTS: Five themes emerged from analysis: (1) managing through hard times (subthemes: intense emotions, medically complex with many symptoms, strategies for self-management), (2) ignored and treated unfairly, (3) actively involved in health (subthemes: seeking health education, suggesting changes), (4) appreciation of caring providers, and (5) violence: expected and enacted. Participants connected the difficult nature of their hospitalization experiences with a variety of sources and outcomes, including strong emotions, variable relationships with providers and a struggle to receive health education. CONCLUSIONS: Nurses who care for patients with psychotic disorders in medical-surgical settings can better meet patients' needs by concentrating on relationship building, especially during initial interactions, and helping patients better manage their medical and psychiatric symptoms through both pharmaceutical and nursing interventions.

Internalization process of stigma of people with mental illness across cultures: A meta-analytic structural equation modeling approach

This meta-analytic study synthesized findings from 108 independent data sets across 22 cultures to investigate whether the stigma internalization model (the internalization of experienced stigma and perceived stigma to self-stigma) is associated with well-being and recovery of people with mental illness. We also examined the moderating role of collectivism in the internalization process. Results of the meta-analytic structural equation modeling suggested that self-stigma is a significant mediator in the relationships between experienced stigma and perceived stigma with well-being and recovery variables (indirect effects = 0.02 to -0.16). Experienced and perceived stigma had significant direct effects on well-being and recovery variables (Bs = 0.07 to -0.21, p < 0.05), suggesting that both external (e.g., public stigma) and internal (i.e., self-stigma) influences of stigma work concurrently to affect recovery and well-being of people with mental illness. The results of the mixed effect three-level meta-analytic models showed that collectivism significantly moderated the relationship between experienced and perceived stigma with self-stigma (Bs = 0.06 to 0.11, p < 0.05). This implied that the more collectivistic a culture is, the stronger the correlation between experienced and perceived stigma with self-stigma. Implications to stigma reduction approaches were discussed.

Discrepancy between experience and importance of recovery components in the symptomatic and recovery perceptions of people with severe mental disorders

BACKGROUND

Personal recovery has become an increasingly important approach in the care of people with severe mental disorders and consequently in the orientation of mental health services. The objective of this study was to assess the personal recovery process in people using mental health services, and to clarify the role of variables such as symptomatology, self-stigma, sociodemographic and treatment.

METHODS

Standardised measures of personal recovery process, clinical recovery, and internalized stigma were completed by a sample of 312 participants in a Severe Mental Disorder program.

RESULTS

Users valued most the recovery elements of: improving general health and wellness; having professionals who care; hope; and sense of meaning in life. Significant discrepancies between perceived experience and relative importance assigned to each of the components of the REE were observed. Regression modeling (χ² = 6.72, p = .394; GFI = .99, SRMR = .03) identified how positive discrepancies were associated with a higher presence of recovery markers (β = .12, p = .05), which in turn were negatively related to the derived symptomatology index (β = -.33, p < .001). Furthermore, the relationship between clinical and personal recovery was mediated by internalized stigma.

CONCLUSIONS

An improvement in psychiatric services should be focused on recovery aspects that have the greatest discrepancy between importance and experience, in particular social roles, basic needs and hope. Personal and clinical recovery are correlated, but the relationship between them is mediated by internalized stigma, indicating the need for clinical interventions to target self-stigma.

Personal Recovery in People With a Psychotic Disorder: A Systematic Review and Meta-Analysis of Associated Factors

Background: Personal recovery (PR) is a subjective, multidimensional concept, and quantitative research using PR as an outcome is rapidly increasing. This systematic review is intended to support the design of interventions that contribute to PR in psychotic disorders, by providing an overview of associated factors and their weighted importance to PR: clinical factors, social factors, and socio-demographic characteristics are included, and factors related to the concept of PR (organized into CHIME dimensions). Methods: A systematic literature search was conducted from inception to March 2020. Quantitative studies that had used a validated questionnaire assessing the concept of PR were included. Mean effect sizes for the relationship between PR-scale total scores and related factors were calculated using meta-analyses. Sources of heterogeneity were examined using meta-regression tests. Results: Forty-six studies, that used (a total of) eight PR measures, showed that in clinical factors, affective symptoms had a medium negative association with PR-scale total scores (r = -0.44, 95%CI -0.50 to -0.37), while positive, negative and general symptoms had small negative correlations. No association was found with neuro-cognition. Social factors (support, work and housing, and functioning) showed small positive correlations. Gender and age differences had barely been researched. Large associations were found for PR-scale total scores with the CHIME dimensions hope (r = 0.56, 95%CI 0.48-0.63), meaning in life (r = 0.48, 95%CI 0.38-0.58) and empowerment (r = 0.53, 95%CI 0.42-0.63); while medium associations were found with connectedness (r = 0.34, 95%CI 0.43-0.65) and identity (r = 0.43, 95%CI 0.35-0.50). Levels of heterogeneity were high, sources included: the variety of PR measures, variations in sample characteristics, publication bias, variations in outcome measures, and cultural differences. Discussion: Most interventions in mental healthcare aim to reduce symptoms and improve functioning. With regard to stimulating PR, these interventions may benefit from also focusing on enhancing hope, empowerment, and meaning in life. The strength of these findings is limited by the challenges of comparing separate CHIME dimensions with questionnaires assessing the concept of PR, and by the high levels of heterogeneity observed. Future research should focus on the interaction between elements of PR and clinical and social factors over time.

Internalized Stigma in People With Mood Disorders: Predictors and Associated Factors

To analyze the predictors of internalized stigma among people with mood disorders, we conducted an analytical observational cross-sectional study with 108 people with mood disorders in a public service setting in Sao Paulo, Brazil. We applied a sociodemographic and clinical questionnaire, the Internalized Stigma of Mental Illness Scale, the Medication Adherence Scale, the Brief Psychiatric Rating Scale-Anchored, and the Herth Hope Index. We analyzed the data using descriptive statistics, average comparison tests, a correlation test, and multiple linear regression. Internalized stigma was associated with symptomatology, history of aggressive behavior, psychiatric hospitalizations, suicide attempts, hopelessness, nonadherence to psychotropic medications, and unemployment. The predictors of internalized stigma were unemployment, more psychiatric symptoms, history of previous suicide attempts, and less hope. Clinical interventions and investigations for stigma reduction and psychosocial rehabilitation should incorporate the factors associated with self-stigma (aggressive behavior, history of psychiatric hospitalizations, suicide attempts, hopelessness, nonadherence to medication, and unemployment).

Ethnographic Insights into the Quality of Life and Experiences of People Living with Schizophrenia in Harare, Zimbabwe

Schizophrenia is a complex and severe mental disorder affecting more than 20 million people worldwide. This study used focused ethnography to explore the everyday lives of 18 people living with schizophrenia in Zimbabwe and its impact on their quality of life (QOL). Data were collected using semi-structured interviews, observational fieldwork, and the short form of the World Health Organization QOL-BREF questionnaire. Those aged 20-40 years experienced poorer QOL than older people. Family dislocation, living with stigma and discrimination, cost of medications and limited and variable access to treatment and support disrupted participants' ability to enjoy life and function socially.

Predictors of subjective recovery from recent-onset psychosis in a developing country: a mixed-methods study

PURPOSE

This study was conducted to: (a) investigate the levels and progress of subjective recovery from recent-onset psychosis; (b) examine its predictive factors and; (c) describe perceived challenges and opportunities affecting recovery. The findings were expected to help inform recovery-oriented psychiatric care in low-income, particularly African, countries.

METHODS

This sequential explanatory mixed-methods study involved 263 service users with recent-onset psychosis from Northwestern Ethiopia. For the quantitative part, a 9-month longitudinal study approach was employed with three time point measurements over 9 months. Predictor variables for subjective recovery from recent-onset psychosis were identified by hierarchical multiple linear regression tests. Following the quantitative survey, individual qualitative interviews were conducted with 19 participants. Interview data were transcribed and thematically analysed.

RESULTS

High mean subjective recovery scores were recorded throughout the study (Questionnaire about the Process of Recovery score ranging from 44.17 to 44.65). Quality of life, internalized stigma, disability, hopelessness, satisfaction with social support, and central obesity were significant predictors of subjective recovery across the three time points. Participants' perceived challenges and opportunities affecting their recovery were categorized into four themes.

CONCLUSION

In Ethiopia, a low percentage of individuals with SMIs initiate psychiatric treatment and many discontinue this to attend spiritual healing. In this study, the Ethiopian SMI patients engaged consistently in psychiatric treatment indicated high mean subjective recovery scores. Devising mechanisms to integrate the psychiatric treatment and spiritual healing sectors are suggested. Approaches to improve quality of life, functioning, hope, internalized stigma and provide need-based social support are suggested.

Stigma toward mental and physical illness: attitudes of healthcare professionals, healthcare students and the general public in Pakistan

BACKGROUND

The evidence base for stigma in mental health largely originates from high-income countries.

AIMS

This study from Pakistan aimed to address the gap in literature on stigma from low- and middle-income countries.

METHOD

This cross-sectional study surveyed 1470 adults from Karachi, Pakistan. Participants from three groups (healthcare professionals, healthcare students and the general public) completed the adapted Bogardus Social Distance Scale (SDS) as a measure of stigma.

RESULTS

All three groups reported higher scores of stigma toward mental disorders compared with physical disorders. SDS scores for mental illness in the general public were significantly higher than in healthcare students (mean difference (MD) 6.93, 95% CI 5.45-8.45, P < 0.001) and healthcare professionals (MD 6.93, 95% CI 5.48-8.38, P < 0.001). However, SDS scores between healthcare students and healthcare professionals were not significantly different (MD 0.003, 95% CI -1.14-1.14, P > 0.99). Being female was associated with lower stigma scores and being over the age of 30 years was associated with higher stigma scores.

CONCLUSIONS

Stigma campaigns in Pakistan need to target the general population. However, evidence of negative attitudes toward mental illness in healthcare students and healthcare professionals supports the need for stronger emphasis on psychiatric education within undergraduate and postgraduate training in Pakistan.

Subjective Recovery in Patients with Schizophrenia and Related Factors

Subjective recovery is a personally perceived recovery involving other factors beyond clinical recovery. This study aims at investigating the factors related to subjective recovery in patients with schizophrenia living in Turkey. This study assessed 120 clinically stable outpatients with schizophrenia or schizoaffective disorder using the clinical and psychosocial scales. Gender, type of the diagnosis of disease, and age of the illness onset were found to be correlated with the subjective recovery. Subjective recovery was significantly correlated with CGI-S (r = - 0.25), total PANSS score (r = - 0.29), global assessment of functioning (r = 0.27), social functioning (r = 0.43), internalized stigma (r = - 0.38), self-esteem (r = 0.56), depression (r = - 0.59), and hopelessness (r = - 0.55). Hopelessness and self-esteem were found to be predictive of the subjective recovery explaining 52% of the variance. It can be argued that efforts to promote hope and self-esteem contribute to the subjective recovery.

Coping strategies in first-episode psychosis: A systematic review

AIMS

This paper reviews and discusses the published information on coping strategies in people with a first-episode psychosis (FEP). The objective is to update knowledge about coping strategies used by people with a FEP, to compare these strategies with those used by other mental disorders, and to examine the relationship between coping strategies and other variables in FEP.

METHOD

A search was conducted using PsycINFO, MEDLINE and PSICODOC between 1995 and 2018 using the following terms: coping strategies or Adaptation, Psychological and FEP.

RESULTS

A total of 167 studies were found, of which 14 were selected for review. The results suggest the need for a multiple and integrated approach, since there are several factors that are involved in the coping strategies (eg, socio-demographic, clinical and psychological variables) used in the different profiles of psychotic spectrum, specifically in FEP.

CONCLUSIONS

The role of coping skills is an important issue in psychopathological research in addition to clinical outcome, especially from the point of view of the patients, their social context and their recovery. Moreover, personalized therapies addressed to personal recovery should be considered to develop better coping specifically addressed to patients' needs.

Factors influencing subjective recovery of people with recent-onset psychosis: A cross-sectional study in a low-income sub-Saharan country

People with psychosis were traditionally believed to have a chronic deteriorating condition with no hope of recovery. Recent studies have shown varied levels of recovery across countries. However, evidence from low-income, particularly African countries is scant. This study aimed to investigate levels of subjective recovery of people with recent-onset psychosis and identify its influencing factors. A cross-sectional study was conducted among 263 outpatients with recent-onset psychosis in a low-income country, Ethiopia. Psychiatric outpatients were randomly selected, and assessed by a set of questionnaires measuring their psychosocial, clinical and physical health conditions. Hierarchical multiple regression tests were used to identify factors influencing subjective recovery. The level of subjective recovery was found to be high, with a mean Questionnaire about the Process of Recovery score of 44.17. Individuals with higher quality of life were found to have significantly better subjective recovery level. Hopeless and centrally obese individuals were found to have significantly lower level of subjective recovery. Despite the limitations associated with a cross sectional study design, the results suggest that individuals with recent-onset psychosis in Ethiopia may have a better level of subjective recovery than those in high-income countries and their recovery is influenced by quality of life, hopelessness and central obesity.

Can Flow Alleviate Anxiety? The Roles of Academic Self-Efficacy and Self-Esteem in Building Psychological Sustainability and Resilience

A growing number of studies suggest that flow experience is associated with life satisfaction, eudaimonic well-being, and the perceived strength of one’s social and place identity. However, little research has placed emphasis on flow and its relations with negative experiences such as anxiety. The current study investigated the relations between flow and anxiety by considering the roles of self-esteem and academic self-efficacy. The study sample included 590 Chinese university students, who were asked to complete a self-report questionnaire on flow, anxiety, self-esteem, and academic self-efficacy. Data were analyzed using structural equation modeling (SEM) with AMOS software, in which both factorial analysis and path analysis were performed. Results revealed that the experience of flow negatively predicted anxiety, and both self-esteem and academic self-efficacy fully mediated the path between flow and anxiety. Specifically, self-esteem played a crucial and complete mediating role in this relationship, while academic self-efficacy mediated the path between self-esteem and anxiety. Our findings enrich the literature on flow experience and help with identifying practical considerations for buffering anxiety and more broadly with fostering strategies for promoting psychological sustainability and resilience.

Effects of perceived social status and discrimination on hope and empowerment among individuals with serious mental illnesses

Hope and empowerment are key elements of recovery in the context of serious mental illnesses (SMI). We examined predictors of hope among individuals with SMI and tested a hypothesized path model in which perceived social status and perceived discrimination adversely impact hope, directly and through their impacts on depressive symptoms. Data from 232 individuals with SMI receiving care in public-sector settings were used in both a multiple linear regression (predicting Herth Hope Scale scores), and in path analyses examining both direct and indirect effects of perceived social status (Social Status Ladder) and perceived discrimination (Everyday Discrimination Scale). Depressive symptoms, perceived social status, and perceived discrimination were predictive of hope. Path analyses revealed that perceived social status has a direct effect on hope and empowerment but also impacts hope through its effects on depression. Similarly, perceived everyday discrimination affects hope and empowerment, though this effect is mediated through its effects on depression. Two alternative models and a trimmed hypothesized model did not fit the data or improve fit. These social determinants of mental health should provoke program and policy change to improve mental health and enhance recovery among persons with SMI.

Perceived and experienced stigma in first-episode psychosis: A 1-year follow-up study

OBJECTIVES

Perceived/experienced stigma and its relationship with clinical outcome were investigated across the first year of treatment in a large sample with first-episode psychosis (FEP).

METHODS

FEP participants (n=112) in the TOP study were investigated at baseline and 1-year follow-up. Perceived/experienced stigma was measured with items from the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0), assessing problems because of barriers and hindrances, and living with dignity because of attitudes and actions of others. Clinical outcome included: symptoms, global functioning, self-rated disability and self-rated life satisfaction.

RESULTS

In the total sample, 46% perceived/experienced stigma at baseline, which decreased significantly to 32% at 1-year follow-up. Perceived/experienced stigma was present in 1/5 at both time-points (Sustained stigma), in 2/5 at only one time-point (Transient stigma), and in 2/5 it was not present at either time-point (No stigma). Compared to the No stigma group, the Sustained stigma group had significantly higher levels of positive, excited and depressive symptoms and self-rated disability, as well as lower levels of global functioning and life satisfaction at 1year follow-up, while the Transient stigma group only had poorer functioning and higher self-rated disability. Yet the outcome variables improved across the first year of treatment in all three stigma groups.

CONCLUSION

Perceived/experienced stigma was common in FEP, yet the rate decreased across the first year of treatment. Although there was some clinical improvement across the first year of treatment irrespective of stigma, stigma was related to poorer clinical outcome in a bidirectional manner. This suggests that perceived/experienced stigma is an important target in the early stages of treatment.

Exploring identity and personal meanings in psychosis using the repertory grid technique: A systematic review

Current research and clinical practice in person-centred approaches highlight the importance of self, identity, and personal meanings in psychosis. Previous research has focused on dimensions of self, but less attention has been paid to the personal meanings involved in identity. The personal construct theory framework and the repertory grid technique (RGT) allow the study of identity and personal meanings within person-centred approaches of psychopathology and treatment in psychosis, as suggested by studies that began more than 40 years ago. However, their contributions have not yet been reviewed. We aimed to systematically review the evidence for the role of identity and personal meanings in psychotic disorders. We performed a systematic search using personal construct and RGT terms in PsycINFO, Web of Science, PubMed, EBSCO, Scopus, and Google Scholar. After identifying 2,574 articles, 15 were included. Nine studies followed an idiographic assessment, and six were nomothetic. Patients reported their subjective experience of isolation in terms of high self-ideal discrepancy and high perceived discrepancy with their significant others, which some studies associated with a lower degree of recovery or with the way in which positive symptoms were construed. Self-fragmentation either decreased with interventions or was associated with recovery. Evidence regarding interpersonal construing was less consistent, but there was a tendency for patients to show a more rigid cognitive structure than controls. To conclude, we found some evidence that self-discrepancies, fragmentation of self, and interpersonal construing are affected in psychosis and potentially modifiable through psychotherapy.

Is sport an untapped resource for recovery from first episode psychosis? A narrative review and call to action

AIM

The objective of this narrative review is to address the question: Should sport-based life skills interventions be developed for young people recovering from first episode psychosis?

METHODS

A prose was developed through a broad, critical narrative review of literatures on (1) first episode psychosis recovery (FEP); and (2) life skills and sport, highlighting the conceptual (and limited empirical) links between the two. This style of review allowed for a critical examination of evidence from seemingly distinct literatures to address a question yet to be explored empirically.

RESULTS

The review process highlighted important overlaps between psychosis recovery and sport. A review of the FEP recovery literature reveals that important components of an individual's recovery following a psychotic episode are: (1) physical activity, (2) opportunities to build life skills, and (3) social connectivity. A review of the sport and life skills literature suggests that sport can be a powerful platform from which to: (1) promote physical activity, (2) teach life skills, and (3) foster social connectivity within vulnerable populations. Despite the clear links between the two fields, mental health interventions that combine both life skills training components and physical activity in a context that promotes social connectivity are scarce to none.

CONCLUSIONS

We suggest that sport-based interventions could be an opportunity to provide life skills training, social connectivity and physical activity opportunities in one intervention to individuals recovering from their first psychotic episode. We call for their development, and provide empirically-based recommendations for intervention design.

The Role of Demoralization and Hopelessness in Suicide Risk in Schizophrenia: A Review of the Literature

Background and Objectives: Demoralization has been defined by hopelessness and helplessness attributable to a loss of purpose and meaning in life. Demoralization is a meaningful mental health concern, frequently associated with suicide risk in medical and psychiatric patients. The aim of this systematic review was to synthesize the recent empirical evidence on demoralization in patients with schizophrenia and to better understand the relationship between demoralization and suicide risk in patients with schizophrenia. Methods: A comprehensive literature search using key words and subject headings was performed following PRISMA guidelines with several bibliographic databases, resulting in the identification of 27 studies. Results: The findings suggested that demoralization is prevalent in patients with schizophrenia and supported the hypothesis that the association between depression and suicide is moderated by hopelessness. In clinical practice, it is important to recognize symptoms of demoralization using appropriate psychological tools to better understand the suffering of patients with schizophrenia and to implement suicide prevention programs.

Conceptualizations of subjective recovery from recent onset psychosis and its associated factors: A systematic review

AIM

There is no standard definition of "subjective recovery" from psychosis, its nature is currently contested and debated among service-users and professionals. Individual studies have explored conceptualizations of subjective recovery from recent onset psychosis, but there have been no previously published systematic reviews on the topic. The aim of this review was to examine and synthesize quantitative and qualitative studies examining the concept of subjective recovery from recent onset psychosis and identify common factors associated with this recovery process.

METHODS

Relevant electronic databases (Medline, CINAHL, PsychInfo and ProQuest Dissertations and Theses) were searched and hand searches were also carried out. Publications in each database from the inceptions of the databases to April 12, 2017 were included. Data from selected articles were extracted using a piloted extraction form and thematic integrative analysis was performed.

RESULTS

Ten studies with different study designs were included in this review. Subjective recovery was conceptualized into 3 main themes: "recovery as outcome", "recovery as process" and "endeavours during recovery". Factors contributing to subjective recovery were categorized into 4 main themes; "treatment related", "illness related", "individual related" and "social environment" related. Non-linear and subjective nature of the process of recovery were reinforced by the review findings.

CONCLUSIONS

Studies in subjective recovery from recent onset psychosis are limited to developed countries. Acquiring hope and self-confidence, overcoming symptoms and stigma through mobilizing all resources available were accentuated in conceptualizing subjective recovery and related factors. Recovery-oriented health care services should acknowledge individual differences and involve service users in their care decisions.

Factors influencing subjective recovery of people with recent-onset psychosis: A cross-sectional study in a low-income Sub-Saharan country

People with psychosis were traditionally believed to have a chronic deteriorating condition with no hope of recovery. Recent studies have shown varied levels of recovery across countries. However, evidence from low-income, particularly African countries is scant. This study aimed to investigate levels of subjective recovery of people with recent-onset psychosis and identify its influencing factors. A cross-sectional study was conducted among 263 outpatients with recent-onset psychosis in a low-income country, Ethiopia. Psychiatric outpatients were randomly selected, and assessed by a set of questionnaires measuring their psychosocial, clinical and physical health conditions. Hierarchical multiple regression tests were used to identify factors influencing subjective recovery. The level of subjective recovery was found to be high, with a mean Questionnaire about the Process of Recovery score of 44.17. Individuals with higher quality of life were found to have significantly better subjective recovery level. Hopeless and centrally obese individuals were found to have significantly lower level of subjective recovery. Despite the limitations associated with a cross sectional study design, the results suggest that individuals with recent-onset psychosis in Ethiopia may have a better level of subjective recovery than those in high-income countries and their recovery is influenced by quality of life, hopelessness and central obesity.

The impact of affective symptoms on personal recovery of patients with severe mental illness

BACKGROUND

Clinical recovery is often defined as remission of symptoms. Personal recovery is described as growing beyond the catastrophic effects of mental illness, sometimes despite ongoing symptoms.

AIMS

To examine the relationship between the severity of clinical symptom domains and personal recovery in patients with severe mental illness (SMI).

METHODS

Symptom severity and personal recovery of 105 outpatients with SMI at Mentrum, part of Arkin Institute for Mental Health in Amsterdam, the Netherlands, were assessed using the Brief Psychiatric Rating Scale-Expanded Version (BPRS-E) and the Mental Health Recovery Measure (MHRM). Correlation and regression analyses were used to investigate the associations.

RESULTS

The multiple regression analysis showed that only affective symptoms significantly predicted personal recovery, whereas neither positive nor negative symptom severity added to the explained variance in the model.

CONCLUSION

The association between affective symptoms and personal recovery in patients with SMI implies that treatment of affective symptoms may advance personal recovery, and/or support of personal recovery may improve mood, whereas focussing on treatment of psychotic symptoms might not be the key to personal recovery. More research is needed to elucidate causal interrelations.

A qualitative study: experiences of stigma by people with mental health problems

OBJECTIVES

Prior research has examined various components involved in the impact of public and internalized stigma on people with mental health problems. However, studies have not previously investigated the subjective experiences of mental health stigma by those affected in a non-statutory treatment-seeking population.

DESIGN

An in-depth qualitative study was conducted using thematic analysis to investigate the experiences of stigma in people with mental health problems.

METHODS

Eligible participants were recruited through a local mental health charity in the North West of England. The topic of stigma was examined using two focus groups of thirteen people with experience of mental health problems and stigma.

RESULTS

Two main themes and five subthemes were identified. Participants believed that (1) the 'hierarchy of labels' has a profound cyclical impact on several levels of society: people who experience mental health problems, their friends and family, and institutional stigma. Furthermore, participants suggested (2) ways in which they have developed psychological resilience towards mental health stigma.

CONCLUSIONS

It is essential to utilize the views and experiences gained in this study to aid understanding and, therefore, develop ways to reduce the negative impact of public and internal stigma.

PRACTITIONER POINTS

People referred to their mental health diagnosis as a label and associated that label with stigmatizing views. Promote awareness and develop improved strategies (e.g., training) to tackle the cyclical impact of the 'hierarchy of labels' on people with mental health problems, their friends and family, and institutional stigma. Ensure the implementation of clinical guidelines in providing peer support to help people to combat feeling stigmatized. Talking about mental health in psychological therapy or health care professional training helped people to take control and develop psychological resilience.

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.

The Relationship Between Clinical and Personal Recovery in Patients With Schizophrenia Spectrum Disorders: A Systematic Review and Meta-analysis

Patients describe experiencing personal recovery despite ongoing symptoms of psychosis. The aim of the current research was to perform a meta-analysis investigating the relationship between clinical and personal recovery in patients with schizophrenia spectrum disorders. A comprehensive OvidSP database search was performed to identify relevant studies. Correlation coefficients of the relationship between clinical and personal recovery were retrieved from primary studies. Meta-analyses were performed, calculating mean weighted effect sizes for the association between clinical and personal recovery, hope, and empowerment. Additionally, associations between positive, negative, affective symptoms, general functioning, and personal recovery were investigated. The results show that heterogeneity across studies was substantial. Random effect meta-analysis of the relationship between symptom severity and personal recovery revealed a mean weighted correlation coefficient of r = -.21 (95% CI = -0.27 to -0.14, P < .001). We found the following mean weighted effect size for positive symptoms r = -.20 (95% CI = -0.27 to -0.12, P < .001), negative symptoms r = -.24 (95% CI = -0.33 to -0.15, P < .001), affective symptoms r = -.34 (95% CI = -0.44 to -0.24, P < .001) and functioning r = .21 (95% CI = -0.09 to 0.32, P < .001). The results indicate a significant small to medium association between clinical and personal recovery. Psychotic symptoms show a smaller correlation than affective symptoms with personal recovery. These findings suggest that clinical and personal recovery should both be considered in treatment and outcome monitoring of patients with schizophrenia spectrum disorders.

Demographic and clinical features related to perceived discrimination in schizophrenia

Perceived discrimination contributes to the development of internalized stigma among those with schizophrenia. Evidence on demographic and clinical factors related to the perception of discrimination among this population is both contradictory and scarce in low- and middle-income countries. Accordingly, the main purpose of this study is to determine the demographic and clinical factors predicting the perception of discrimination among Mexican patients with schizophrenia. Two hundred and seventeen adults with paranoid schizophrenia completed an interview on their demographic status and clinical characteristics. Symptom severity was assessed using the Positive and Negative Syndrome Scale; and perceived discrimination using 13 items from the King's Internalized Stigma Scale. Bivariate linear associations were determined to identify the variables of interest to be included in a linear regression analysis. Years of education, age of illness onset and length of hospitalization were associated with discrimination. However, only age of illness onset and length of hospitalization emerged as predictors of perceived discrimination in the final regression analysis, with longer length of hospitalization being the independent variable with the greatest contribution. Fortunately, this is a modifiable factor regarding the perception of discrimination and self-stigma. Strategies for achieving this as part of community-based mental health care are also discussed.

The impact of self-stigmatization on medication attitude in schizophrenia patients

Negative attitudes towards medication in schizophrenia patients are one major factor contributing to non-adherence behavior. Besides, self-stigmatization represents another frequent and important obstacle in patients suffering from psychotic disorders. Here, we investigated possible associations between medication adherence attitude and the extent of self-stigmatization, while also exploring factors related to self-stigmatization. Sociodemographic characteristics, clinical variables, medication attitude and self-stigmatization were assessed among 81 subjects with schizophrenia or schizoaffective disorder. The cross-sectional data was then analyzed by multivariate analyses. A more positive attitude towards medication was predicted by better insight into illness, lower degree of self-stigmatization and good subjective knowledge about medication (adjusted R² = 0.23). Furthermore, a higher level of self-stigmatization was associated with lower subjective wellbeing, more severe depressive symptoms and male gender (adjusted R² = 0.58). Other clinical variables had no additional predictive value for medication adherence attitude or the extent of self-stigmatization. Our findings support the notion that self-stigmatization is an influential factor on medication attitude that should therefore be appreciated in clinical practice. Besides this, special emphasis should be taken on depressive symptoms and reduced wellbeing, especially in male patients, to lower the extent of self-stigmatization.

Self-stigma as a barrier to recovery: a longitudinal study

Stigma limits life opportunities of persons with mental illness. Self-stigma, the internalization of negative stereotypes, undermines empowerment and could hinder recovery. Here we examined self-stigma's effect on recovery among 222 disability pensioners with mental illness over 2 years, controlling for age, gender, symptoms and recovery at baseline measured by the Recovery Assessment Scale. More self-stigma at baseline was associated with a significant decrease in recovery after 1 year (not significant after 2 years). An increase of self-stigma from baseline to follow-up predicted less recovery 1 and 2 years later. Interventions that reduce self-stigma could therefore improve recovery.

The complex relationship between self-reported 'personal recovery' and clinical recovery in schizophrenia

Self-reported 'personal recovery' and clinical recovery in schizophrenia (SRPR and CR, respectively) reflect different perspectives in schizophrenia outcome, not necessarily concordant with each other and usually representing the consumer's or the therapist's point of view. By means of a cluster analysis on SRPR-related variables, we identified three clusters. The first and third cluster included subjects with the best and the poorest clinical outcome respectively. The second cluster was characterized by better insight, higher levels of depression and stigma, lowest self-esteem and personal strength, and highest emotional coping. The first cluster showed positive features of recovery, while the third cluster showed negative features. The second cluster, with the most positive insight, showed a more complex pattern, a somewhat 'paradoxical' mixture of positive and negative personal and clinical features of recovery. The present results suggest the need for a characterization of persons with schizophrenia along SRPR and CR dimensions to design individualized and integrated treatment programs aimed to improve insight and coping strategies, reduce stigma, and shape recovery styles.

Personal resources and depression in schizophrenia: The role of self-esteem, resilience and internalized stigma

Depression in schizophrenia represents a challenge from a diagnostic, psychopathological and therapeutic perspective. The objective of this study is to test the hypothesis that resilience and self-stigma affect depression severity and to evaluate the strength of their relations in 921 patients with schizophrenia. A structural equation model was tested where depression is hypothesized as affected by resilience, internalized stigma, gender and negative symptoms, with the latter two variables used as exogenous covariates and the former two as mediators. The analysis reveals that low resilience, high negative symptoms, female gender were directly associated with depression severity, and internalized stigma acted only as a mediator between avolition and resilience, with similar magnitude. The cross-sectional study design and the variable selection limit the generalizability of the study results. The model supports a complex interaction between personal resources and negative symptoms in predicting depression in schizophrenia. The clinical implication of these findings is that personal resources could be a significant target of psychosocial treatments.

The impact of stigma on emotional distress and recovery from psychosis: The mediatory role of internalised shame and self-esteem

Internalised shame and self-esteem have both been proposed to play an integral role in the relationship between stigma and its negative psychological sequelae in people who experience psychosis, but there has been little quantitative exploration to examine their roles further. The aim of this study was to examine the relationship of stigma (experienced and perceived) with emotional distress and recovery in psychosis, and to examine internalised shame and self-esteem as potential mediators. A total of 79 participants were included for the purposes of this study. Participants were administered a battery of assessment measures examining experienced and perceived stigma, internalised shame, self-esteem, depression, hopelessness, and personal recovery. Results illustrated that stigma (experienced and perceived) was significantly associated with internalised shame, low self-esteem, depression, hopelessness and poor personal recovery. Stigma (experienced and perceived) and its relationship with depression, hopelessness and personal recovery was mediated by both internalised shame and low self-esteem. In conclusion, stigma can have significant negative emotional consequences and impede recovery in people with psychosis. This may indicate that stigma needs to be addressed therapeutically for people with psychosis with a particular emphasis on addressing internalised shame and low self-esteem.

Experienced stigma and its impacts in psychosis: The role of social rank and external shame

OBJECTIVES

Experienced stigma is detrimental to those who experience psychosis and can cause emotional distress and hinder recovery. This study aimed to explore the relationship between experienced stigma with emotional distress and recovery in people with psychosis. It explored the role of external shame and social rank as mediators in these relationships.

DESIGN

A cross-sectional design was implemented.

METHODS

Fifty-two service users were administered a battery of questionnaires examining experienced stigma, external shame, social rank, personal recovery, positive symptoms, depression, and anxiety. Correlation and multiple regression analysis were conducted on the data. Where appropriate, mediation analysis was employed to explore social rank and external shame as mediatory variables.

RESULTS

Experienced stigma was significantly related to shame (social rank and external shame), positive symptoms, emotional distress (depression and anxiety), and personal recovery. The impact of experienced stigma on depression was mediated by external shame. Social rank was a mediator between experienced stigma and personal recovery only.

CONCLUSION

People with psychosis who have experienced stigma are likely to experience emotional distress and be inhibited in their recovery. This was found to be partly mediated by external shame and low social rank. Clinical approaches to stigma need to target these as potential maintenance factors.

PRACTITIONER POINTS

Experienced stigma is significantly related to shame (social rank and external shame) emotional distress, and reduced personal recovery. External shame mediated the relationship between experienced stigma and depression in psychosis. Social rank mediated the relationship between experienced stigma and personal recovery. Clinical approaches to stigma should include the assessment of external shame and low social rank.

Stigma and social support in substance abuse: Implications for mental health and well-being

Individuals with substance abuse may suffer from severe public and internalized stigma. Little is known about how social support can reduce stigma and improve mental health and well-being for them. This research examined how perceived stigma influences individuals in treatment for substance abuse, and whether internalized stigma and shame are mechanisms which link social support with better mental health and well-being. Sixty-four participants in treatment for substance abuse (alcohol, drugs), aged between 18 and 64, completed an online survey measuring perceived stigma, internalized stigma, shame, perceived social support, and mental health and well-being (self-esteem, depression and anxiety, sleep). We found that perceived stigma was associated with lower self-esteem, higher depression and anxiety, and poorer sleep. Furthermore, perceived social support followed the opposite pattern, and was associated with higher self-esteem, lower depression and anxiety, and better sleep. The effects of perceived stigma and of perceived social support on our outcome measures were mediated by internalized stigma and by internalized shame. Helping individuals with substance abuse to utilize their social support may be fruitful for combatting the negative impact of internalized stigma and shame on mental health and well-being.

An Integrative Cognitive Model of Internalized Stigma in Psychosis

Background:Internalized stigma is a significant difficulty for those who experience psychosis, but it has never been conceptualized using cognitive theory.Aims:The aim of this paper is to outline a cognitive model conceptualizing internalized stigma experienced by people who also experience psychosis.Method:Previous literature is reviewed, critiqued and synthesized to develop the model. It draws upon previous social cognitive models of internalized stigma and integrates cognitive behavioural theory and social mentality theory.Results:This paper identifies key cognitive, behavioural and emotional processes that contribute to the development and maintenance of internalized stigma, whilst also recognizing the central importance of cultural context in creating negative stereotypes of psychosis. Moreover, therapeutic strategies to alleviate internalized stigma are identified. A case example is explored and a formulation and brief intervention plan was developed in order to illustrate the model in practice.Conclusion:An integrative cognitive model is presented, which can be used to develop individualized case formulations, which can guide cognitive behavioural interventions targeting internalized stigma in those who experience psychosis. More research is required to examine the efficacy of such interventions. In addition, it is imperative to continue to research interventions that create change in stigma at a societal level.