Stigma and its correlates among patients with bipolar disorder: A study from a tertiary care hospital of North India

Research on clinical aspects of bipolar disorder: A review of Indian studies

Background

Bipolar disorder is one of the severe mental disorders that are associated with significant morbidity of the patients. Despite advancements in our understanding about the disorder, it remains a challenging proposition to treat bipolar disorder, largely since the prophylactic treatment of the disorder requires assessment of complex clinical algorithms. The revisions of the classificatory systems have also changed the conceptualization of the disorder. In this background, we conducted a review of the Indian studies conducted on the clinical aspects of bipolar disorder.

Methods

A narrative review was conducted with focus on the literature published from India. The databases searched included PubMed, Scopus, and Google Scholar, and articles published over the last 15 years by Indian authors were included for this review.

Results

In our review, we could access a substantial volume of research published from India. We could identify studies that catered to most of the relevant themes in bipolar disorder including epidemiology, etiology, comorbidities, stigma, disability, clinical course, cognitive profile, pathways to care, and recovery.

Conclusion

The research trajectory was in line with the research conducted elsewhere in the world. However, certain dissimilarities in terms of focus could also be observed. The possible reason behind this deviation could be the difference in clinical need and unique challenges faced in the management and rehabilitation of patients in bipolar disorder in Indian scenario.

Examining the association between perceived stigma, its correlates, and restrictions in participation among persons with disabilities in Nepal: a cross-sectional study

BACKGROUND

Disability stigma in low- and middle-income countries is one of the most persistent and complex barriers limiting persons with disabilities (PwDs) from enjoying their rights and opportunities. Perceived stigma among PwDs and its impact on participation restriction is rarely assessed in Nepal.

OBJECTIVE

This study aimed to measure the extent of perceived stigma by PwDs, identify its relationships with specific demographic factors, and assess the impact on social participation.

METHODS

A cross-sectional survey was conducted between May and July 2022 among PwDs in Nepal, with a sample of 371. The Explanatory Model Interview Catalog (EMIC) stigma scale and P-scale suitable for people affected by stigmatized conditions were used, and the generated scores were analyzed. One-way ANOVA was performed to determine group differences for sociodemographic variables, and linear regression and correlational analysis were used to identify their association and measure the strength and direction of the relationship.

RESULTS

The mean stigma score was 16.9 (SD 13.8). 42% of respondents scored higher than the mean. The scores differed significantly by disability type, caste and ethnicity, education, occupation, and household wealth. Over 56% reported participation restriction, and 38% had severe/extreme restriction. Approximately 65% of participants with intellectual disabilities, 53% with multiple disabilities, and 48.5% of persons with severe or profound disabilities experienced severe or extreme restrictions. Perceived stigma had a positive correlation with Disability type (r = 0.17, P < 0.01) and negative correlations with Severity of disability (r= -0.15, P < 0.05), and Household wealth (r= -0.15, P < 0.01). Education was inversely associated with both stigma (r= -0.24, P < 0.01), and participation restriction (β= -9.34, P < 0.01). However, there was no association between stigma and participation restriction (β= -0.10, P > 0.05).

CONCLUSION

All participants exhibited stigma in general; however, the severity varied based on disability type, level of education, and sociocultural circumstances. A large proportion of participants reported facing a high degree of restrictions in participation; however, no association was detected between perceived stigma and participation restriction. A significant negative linear correlation was observed between education and participation restriction. Stigma reduction programs focusing on education and empowerment would be especially important for overcoming internalized stigma and increasing the participation of PwDs.

The Relationship Between Religious Coping and Internalized Stigma Among Patients With Bipolar Disorder

BACKGROUND

Stigmatization is a situation that results from the negative perspective of society toward individuals with certain mental and physical illnesses and has negative effects. It has been observed that there are not enough studies in the literature investigating the attitudes of individuals with mental illness to cope with lifelong difficulties such as stigma and especially their religious coping attitudes. However, there are many clinical studies on general psychology and religious coping with varying results. Our aim in this research is to reveal the association between religious coping and internal stigma among bipolar disorder patients.

METHODS

The religious coping scale and the Internalized Stigma in Mental Illness (ISMI) scale were administered to 79 patients with bipolar disorder. The obtained data were analyzed using IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States).

RESULTS

Forty-two (53.1%) patients were female and 37 (46.9%) were male, the mean age was 43.41±12.57, and the mean follow-up period was 11.95±9.15 years. A positive correlation was found between negative religious coping and discrimination experience, alienation, and social withdrawal in bipolar disorder patients. A significant negative correlation was found between discrimination experience, alienation and social withdrawal, and positive religious coping.

CONCLUSIONS

The correlation of religious coping attitudes with discrimination experience, alienation, and social withdrawal makes us think that religious coping methods may be one of the issues to be considered when dealing with self-stigma in bipolar disorder patients. In addition, the relationship between religious coping and self-stigmatization in mental illnesses can add a new dimension to psychosocial approaches. It would be beneficial for authors interested in religion and social psychology to focus on more extensive research on this subject.

Self-stigma and bipolar disorder: A systematic review and best-evidence synthesis

BACKGROUND

Bipolar disorder is a severe and chronic mental illness characterized by recurrent major depressive episodes and mania or hypomania. In addition to the burden of the disease and its consequences, self-stigma can impact people with bipolar disorder. This review investigates the current state of research in self-stigma in bipolar disorder.

METHODS

An electronic search was carried out until February 2022. Three academic databases were systematically searched, and best-evidence synthesis was made.

RESULTS

Sixty-six articles were related to self-stigma in bipolar disorder. Seven key themes were extracted from these studies: 1/ Comparison of self-stigma in bipolar disorder and other mental illnesses, 2/ Sociocultural context and self-stigma, 3/ Correlates and predictors of self-stigma, 4/ Consequences of self-stigma, 5/ Treatments and self-stigma, 6/ Management of self-stigma, and 7/ Self-stigma and recovery in bipolar disorder.

LIMITATIONS

Firstly, a meta-analysis could not be performed due to the heterogeneity of the studies. Secondly, limiting the search to self-stigma has excluded other forms of stigma that also have an impact. Thirdly, the under-reporting of negative or nonsignificant results due to publication bias and unpublished studies might have limited the accuracy of this reviews' synthesis.

CONCLUSION

Research on self-stigma in persons with bipolar disorder has been the focused on different aspects, and interventions to reduce self-stigmatization have been developed, but evidence of their effectiveness is still sparse. Clinicians need to be attentive to self-stigma, its assessment, and its empowerment in their daily clinical practice. Future work is required to establish valid strategies to fight self-stigma.

Stigma in people living with bipolar disorder and their families: a systematic review

BACKGROUND

Stigma affects different life aspects in people living with bipolar disorder and their families. This study aimed to examining the experience of stigma and evaluating predictors, consequences and strategies to combat stigma in people with bipolar disorder and their families.

METHODS

We conducted a systematic review according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) in 2022. We extensively reviewed six online databases (PubMed, Scopus, Medline, EMBASE, Web of Science and Google Scholar). Articles published in the English language about stigma in people living with bipolar disorders and their families were included.

RESULTS

A total of 42,763 articles were retrieved, of which 40 articles from 14 countries were included in this study (n = 7417 participants). Of the 40 articles, 29 adopted quantitative methods (72.5%), two used mixed-methods (5%), eight used qualitative (20%) methods, and one was a case series (2.5%). The results of the studies were categorized into four themes: 1. Stigma experienced by people living with bipolar disorders and their families, 2. Predictors of stigma in people living with bipolar disorders and their families, 3. Consequences of stigma in people living with bipolar disorders and their families, 4. Effective interventions and strategies to reduce stigma in people living with bipolar disorders and their families.

CONCLUSION

The results of this study might be useful to design psychiatric cognitive interventions to reduce stigma in people living with bipolar disorders and their families and designing community-based interventions to normalize bipolar disorder at the community level.

[Self-stigma and functioning in patients with bipolar disorder]

Self-stigma of people with bipolar disorder is an underestimated problem, with serious consequences in terms of clinical severity and social and professional functioning.

OBJECTIVES

This study aimed to evaluate self-stigma in patients with bipolar disorder, to identify socio-demographic and clinical factors associated with it and to analyze the links between self-stigma and functioning in this population.

METHODS

We conducted a cross-sectional, descriptive and analytic study including 61 patients with bipolar disorder meeting criteria of remission. We used the internalized stigma of mental illness (ISMI) to investigate self-stigma, and the functioning assessment short test (FAST) to assess functioning.

RESULTS

The mean age of patients was 43.4 years. The sex ratio was 2.4. Half of the patients were single or divorced (50 %). They had secondary or university education in 69 % of cases and were professionally inactive in 59 % of cases. The socioeconomic level was low or medium in 92 % of cases. A personal judicial record was found in 16 % of patients, a suicide attempt in 41 % of cases. Most patients in our series had bipolar I disorder (92 %). The mean age at onset of the disease was 23.5 years, with a mean duration of disease progression of 20 years. Patients were hospitalized an average of 5.9 times. Most patients (90 %) exhibited psychotic features during their mood relapses. The mean duration of the last remission was 27.9 months. Patients had regular follow-ups at our consultations in 87 % of cases. Among the patients included in the study, 8 % were on long-acting neuroleptics. The mean score on the internalized stigma of mental illness was 2.36±0.56. More than half of our patients (59 %) were self-stigmatized. Discrimination and alienation were found in 51 % of cases, followed by resistance to stigmatization (43 %) and assimilation of stereotypes (41 %). Regarding functioning, a global impairment was noted in more than two thirds of patients (71 %). An alteration in professional functioning was found in 82 % of cases and in cognitive functioning in 69 % of cases. Disruption of the financial sphere concerned 43 % of the patients, and the relational sphere 41 % of them. Autonomy was altered in 41 % of patients. Analysis of the relationships between self-stigma and characteristics of the study population revealed statistically significant associations between higher self-stigma scores and single or divorced status, low socio-economic level and judicial record. In terms of clinical parameters, the mean self-stigma score was significantly associated with a higher total number of thymic episodes and hospitalizations, a longer cumulative duration of hospitalizations and a shorter duration of the last remission. In addition, the mean self-stigma score was associated with significantly more impaired functioning.

CONCLUSIONS

Our study underlines the need to work towards the implementation of management modalities aimed at combating the self-stigmatization of patients with bipolar disorder and mitigating its negative consequences during the course of the disease.

The process of stigma experience in the families of people living with bipolar disorder: a grounded theory study

BACKGROUND

One of the most challenging issues faced by families of people living with bipolar disorder is stigma. This study was conducted to explain the process of stigma experience in the families of people living with bipolar disorder using the grounded theory method.

METHODS

Data for this study were collected through semi-structured interviews with participants in Razi Psychiatric Hospital in Tehran, Iran, via purposive sampling and field notetaking. The dependability, conformability, and transferability measures were included to support the data accuracy and robustness, and MAXQDA 2020 software was used to facilitate data coding. The Strauss-Corbin method was used to analyse the data.

RESULTS

A total of 20 family members of people living with bipolar disorder, four people living with bipolar disorder, and three mental health professionals participated in this study. The analysis of participants' experiences led to identifying 64 subcategories, 21 categories, and six main concepts, including social deprivation, being labelled, cultural deficiency and lack of awareness, economic challenges, forced acceptance of the existing situation, and social isolation.

CONCLUSION

Families of people living with bipolar disorder experience social deprivation, social isolation, and social rejection, which have irreparable consequences for them. Overcoming stigma in these families should be a priority of policymakers and planners in the field of psychosocial health.

Patients' Perspective of the Impacts of Group Psychoeducation for Bipolar Disorder: A Qualitative Study

ABSTRACT

Little is known regarding the mechanisms involved in the clinical improvement of patients with bipolar disorder (BD) after group psychoeducation. We aimed at investigating these mechanisms by focusing on their subjective experience. Thirteen patients with BD aged 35.54 (SD, 12.06) were recruited. Interviews were analyzed using thematic analysis. Four high-order themes were identified: a) relationship among patients, b) effect of the facilitation style, c) program-related factors, and d) subjective impacts. "Relationships among patients" included a lower-ordered theme evoked by all participants, that is, "shared experiences." Shared experiences included acknowledging that BD has a neurobiological substrate and that its manifestations are similar in BD; the social support and empowering message of those who have managed to exert control over the illness were also highlighted. Our results shed some light on the mechanisms underlying the effectiveness of group psychoeducation. The shared experience of patients seems to play an important role, probably through destigmatization.

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.

Functional Disability in Patients with Mood Disorders at St Paul's Hospital Psychiatry Clinic, Addis Ababa, Ethiopia, 2019

Background

Functional disability is defined as limitations in performing socially defined roles and tasks expected within a sociocultural and physical environment. Functionality is a result of good mental health care. This study aimed to assess the magnitude and determinants of functional disability among patients with a mood disorders treated at St Paul's Hospital outpatient psychiatry clinic, Addis Ababa, Ethiopia in 2019.

Methods

This was a cross-sectional study. We used consecutive sampling to select respondents. Data were collected through face-to-face interviews using the 12-item World Health Organization Disability Assessment Schedule version 2.0. Data were entered into EpiData 3.1 and exported to SPSS 22.0 for analysis. Linear regression analysis was used to identify significant variables associated with outcomes.

Results

This study enrolled 235 respondents with a 100% nonresponse rate, and 62.5% were diagnosed with major depressive disorder. Mean disability score was 30.2%±32.4%. Nearly a quarter of respondents had had difficulties every day with day-to-day activity for the past 30 days. Current level of improvement (no change, β=10.5, 95% CI 3.85-17.2), relapse (β=6.15, 95% CI 1.34-10.9) and self-stigma (β=4.36, 95% CI 1.39-7.33) were strong predictors of disability score (P<0.05).

Conclusion

This study found a mean disability score of 30.2%. Current level of improvement and self-stigma were variables associated with disability, so working with stakeholders to focus on patients' clinical improvement from their illness and self-stigma will be vital to enhance their functionality.

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.

Stigma in Bipolar Affective Disorder: A Systematic Quantitative Literature Review of Indian Studies

BACKGROUND

Bipolar affective disorder (BPAD) is one of the most common severe mental illnesses that cause morbidity. Stigma can negatively influence the disease experience in patients with BPAD. Significant differences are observed in the attributes of stigma across the various sociocultural milieus. The current review was thus conducted to compile the evidence regarding the burden and correlates of various forms of stigma in BPAD in India.

METHODS

An exhaustive literature review was conducted in PubMed, MedIND, and Google Scholar to identify Indian studies conducted on stigma in BPAD. The broad themes in various forms of stigma were identified (qualitative analysis). Quantitative analysis of measures of stigma was done, calculating the effect size in BPAD and comparator groups (schizophrenia and anxiety disorders) using standardized mean difference.

RESULTS

Overall, 12 studies could be identified for qualitative analysis, and 5 were used for quantitative analysis. Overall, the current evidence points out that the stigma in BPAD is less than that in schizophrenia but more than that in anxiety disorders. Internalized stigma in BPAD is correlated with poor self-esteem, reduced community participation, and low quality of life. Caregivers of patients with BPAD also experience significant stigma.

CONCLUSIONS

The review shows that stigma in BPAD is substantial. It also draws attention to the fact that the research regarding stigma in BPAD is lagging behind. This review also provides a platform to develop an intervention in the Indian scenario, where further research should be carried out.

Stigma Resistance and Its Associated Factors among Patients with Mood Disorder at St. Paul's Hospital and Millennium Medical College, Addis Ababa, Ethiopia, 2019

Background

Stigma resistance is described as the capacity to counteract or remain unaffected by the stigma of mental illness. Patients who have high stigma resistance have shown good treatment outcome, so working on this issue is crucial since little is known about the stigma resistance level among patients with mood disorders.

Objectives

To determine the magnitude and determinant factors of stigma resistance among patients with mood disorder attending at St. Paul's Hospital.

Methods

A cross-sectional study design was conducted on 238 study samples, and systematic random sampling was used to get the study participants. Internalized Stigma of Mental Illness Scale was used to measure stigma resistance. Data was entered using EpiData 3.1 and exported to the Statistical Package for Social Science 22.0 for analysis. Linear regression analysis (P < 0.05) was used to identify a significant association between the outcome and predictor variable.

Results

Out of 238 study samples, 235 patients took part with a 99% response rate. The overall percentage of stigma resistance was 49.5%. Low educational status (B = −1.465, 95% CI (-2.796, -0.134), P ≤ 0.031), disability (B = −0.064, 95% CI (-0.102, -0.026), P ≤ 0.001), nonadherence due to stigma (B = −1.365, 95% CI (-2.151, -0.580), P ≤ 0.001), duration of treatment (B = 0.091, 95% CI (0.042, 0.141), P ≤ 0.001), internalized stigma (B = −2.948, 95% CI (-3.642, -2.254), P ≤ 0.001), and self-esteem (B = 1.859, 95% CI (0.812, 2.906), P ≤ 0.001) were significantly associated with stigma resistance.

Conclusion

This study found that only half of the patients had stigma resistance. Low educational status, high self-stigma, low self-esteem, disability, and short duration of treatment were negatively associated with stigma resistance, so working on those modifiable identified factors with focal stakeholders will be crucial to promote the stigma resistance level of patients with mood disorder.

Internalized stigma among patients with mood disorders in Ethiopia: a cross-sectional facility-based study

Background

Information on the degree of internalized stigma experienced by patients with mood disorders in Ethiopia is limited. This study attempted to assess the levels of internalized stigma and factors associated with it in patients with mood disorders who were on follow-up as an outpatient in a Psychiatry clinic at Saint Paul’s Hospital, Addis Ababa, Ethiopia.

Methods

A facility-based cross-sectional study employed, and a consecutive sampling technique was used to get study participants (235 cases with mood disorders). Internalized stigma of mental illness scale used to assess stigma of study subjects. The collected data were cleaned, checked for completeness, coded and entered into Epi-data version 3.1 data entry software and exported to SPSS version 20 statistical software for analysis. Univariate linear regression analysis was done to see the association between dependent and independent variables at P-value < 0.25 and multivariate linear regression analysis was done to identify predictor variables at P-value < 0.05.

Results

Nearly one-third (31.5%) of the patients had moderate or high levels of internalized stigma, and more than half (54.9%) of the respondents had moderate or high stigma resistance and self-esteem score of (67.2%). About a quarter (27.7%) had moderate to high levels of discrimination experience and a similar proportion (26.4%) had moderate to severe or extreme disability. Females had significantly higher internalized stigma (std. β = .169 with P < 0.01) than men. Adherence to medication was significantly correlated with lower internalized stigma (std. β = − .212 with P < 0.01).

Conclusions

These findings suggested that moderate to high internalized stigma occurred among approximately 1 in 3 people with a mood disorder in the urban city of Ethiopia. So, working on adherence to medication, self-esteem of patients and psycho-education about stigma is crucial to reducing the internalized stigma of people with a mood disorder and special attention should give to female patients.

Subjective cognitive dysfunction in patients with bipolar disorder: The prevalence, related factors and effects on predicting psychosocial functioning and suicidal ideation

Persistent cognitive deficits are prevalent during all stages of bipolar disorder (BD). However, few studies have examined subjective cognitive complaints in patients with BD. This study aimed to investigate the prevalence and relevant factors of subjective cognitive functioning and its potential effects on predicting psychosocial functioning and suicidal ideation in BD. Ninety-two patients with BD type I (including 42 depressed patients and 50 euthymic patients) and 60 healthy individuals were recruited for this study. All participants were assessed with a battery of neuropsychological tests examining attention and processing speed, visual memory, working memory and executive functions, as well as the Cognitive Complaints in Bipolar Disorder Rating Assessment, the Global Assessment of Functioning scale and the Beck Scale for Suicide Ideation. Bipolar patients exhibited worse subjective cognitive dysfunction compared with healthy individuals, and depressed patients expressed more cognitive complaints than euthymic bipolar patients. In bipolar group, psychosocial functioning, suicidal ideation and occupational status were the main relevant factors of subjective cognitive functioning. Subjective cognitive functioning could also predict psychosocial functioning and suicidal ideation. Depressive symptoms moderated the associations between objective cognitive functioning and suicidal ideation, but could not moderate the correlations between cognitive functioning and psychosocial functioning. These findings suggest that subjective cognitive assessment should be further emphasized in clinical practice.

Understanding social withdrawal in euthymic bipolar patients: The role of stigma

Social withdrawal acts as a risk factor in mental health, disturbing clinical management and quality of life in euthymic bipolar patients. However, no previous study has analyzed what variables might predict it. We conducted a cross-sectional study in which 49 euthymic bipolar patients were assessed. The analysis showed that taken together, stereotype endorsement, discrimination experience and control over illness as measured by the ISMI, together explained 80.4% of the variability in social withdrawal. In conclusion, an early assessment of self-stigma and perception of control over illness would help euthymic patients to improve their social situation, reducing social withdrawal.

Stigma Resistance and Its Associated Factors among People with Bipolar Disorder at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia

BACKGROUND

Stigma resistance is the capacity to cope and remain unaffected by mental illness stigmatization. In bipolar patients, having low stigma resistance may result in a higher internalized stigma, low self-esteem, and poor treatment outcome. In Ethiopia, the prevalence of stigma resistance among bipolar patients is not well known. Therefore, this study is aimed at assessing the prevalence of stigma resistance and its associated factors among bipolar patients at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia.

METHOD

An institutional-based cross-sectional study was conducted from May 8^th to June 14^th, 2016, at Amanuel Mental Specialized Hospital. The study participants were selected using a systematic random sampling technique. The stigma resistance subscale of the internalized stigma of mental illness was used to measure stigma resistance. Bivariable and multivariable logistic regression was computed to identify factors associated with stigma resistance. Accordingly, variables with P values of less than 0.05 were considered as statistically significant predictors of stigma resistance with a 95% confidence interval.

RESULTS

In this study, 418 participants completed the interview with a response rate of 98.8%. The prevalence of low stigma resistance was 56.9% (95%CI = 51.9-61.6%). Being unemployed (AOR = 1.65; 95%CI = 1.35-1.87), high internalized stigma (AOR = 3.04; 95%CI = 1.83-5.05) and low self-esteem (AOR = 2.13; 95%CI = 1.72-6.76) were significantly associated with low stigma resistance. Conclusions and Recommendation. More than half of the bipolar patients attending the Amanuel Mental Specialized Hospital had low stigma resistance. Therefore, stigma reduction programs have focused on improving self-esteem and reducing internalized stigma to increase their stigma resistance. Mental health information dissemination regarding community support and reengagement of people with bipolar disorder is highly recommended.

Work motivation in patients with bipolar disorder: Associated factors

BACKGROUND

Occupational functioning is severely impaired in patients with bipolar disorder (BD). Work motivation (WM), defined as the psychological processes that determine the direction, intensity, and persistence of action within the work, is an essential component of work-related functioning.

AIM

To assess whether WM is affected in patients with BD and which clinical and sociodemographic factors are related to low WM.

METHODS

In all, 95 euthymic BD patients were invited to answer the Motivation for Work Questionnaire and the Rating Scale on Subjective Cognitive Deficits in Bipolar Disorder (COBRA).

RESULTS

A total of 49.5% ( n = 47) of the patients were classified in the Low Motivated (LM) group. Unemployment and the report of more subjective cognitive complaints were predictors of poor WM in this sample ((OR) = 3.01 and 7.10, respectively).

CONCLUSIONS

Perceived cognitive deficits related to the disorder and current unemployment negatively impact WM in patients with BD. In addition to symptomatic recovery, the need of the inclusion of personal and occupational areas in the comprehensive treatment of patients with BD is necessary.

Self-stigma, stigma coping and functioning in remitted bipolar disorder

OBJECTIVE

Stigma has a deleterious effect on functioning in individuals with bipolar disorder (BD). However, there has been no research investigating how stigma coping predicts self-stigma and functioning in BD. Furthermore, how different stages of self-stigma might affect functioning is unclear. The following hypotheses were examined: (1) Stigma coping by withdrawal and secrecy was associated with more self-stigma; (2) Stigma coping by withdrawal and secrecy was associated with worse social functioning; and (3) Later stages of self-stigma were associated with worse social functioning.

METHODS

A random sample of remitted BD in a regional psychiatric clinic was examined using a cross-sectional design (n = 115). Self-stigma was measured using the Chinese versions of Self-Stigma of Mental Illness Scale (C-SSMIS). Social functioning was assessed using the Functional Assessment Short Test (FAST). Stigma coping was evaluated using the Stigma Coping Orientation Scale (SCOS).

RESULTS

Multiple regression analysis revealed that coping by secrecy was associated with the stereotype agreement subscale of C-SSMIS, while coping by withdrawal was associated with the C-SSMIS self-concurrence and self-esteem decrement subscales. Another regression analysis showed that FAST total score was associated with the self-esteem decrement subscale of C-SSMIS and the severity of depressive and manic symptoms.

CONCLUSION

We showed that self-esteem decrement, the final stage of self-stigma, was the most crucial stage in determining psychosocial functioning. Our findings suggested that stigma-reduction intervention should be arranged during the early stage of BD and targeted at various dysfunctional stigma coping.

Out of the silos: identifying cross-cutting features of health-related stigma to advance measurement and intervention

BACKGROUND

Many health conditions perceived to be contagious, dangerous or incurable, or resulting in clearly visible signs, share a common attribute - an association with stigma and discrimination. While the etiology of stigma may differ between conditions and, sometimes, cultural settings, the manifestations and psychosocial consequences of stigma and discrimination are remarkably similar. However, the vast majority of studies measuring stigma or addressing stigma through interventions employ a disease-specific approach.

MAIN BODY

The current paper opposes this siloed approach and advocates a generic concept of 'health-related stigma' in both stigma measurement and stigma interventions. Employing a conceptual model adapted from Weiss, the current paper demonstrates the commonalities among several major stigmatized conditions by examining how several stigma measurement instruments, such as the Social Distance Scale, Explanatory Model Interview Catalogue, Internalized Stigma of Mental Illness, and Berger stigma scale, and stigma reduction interventions, such as information-based approaches, contact with affected persons, (peer) counselling, and skills building and empowerment, were used successfully across a variety of conditions to measure or address stigma. The results demonstrate that 'health-related stigma' is a viable concept with clearly identifiable characteristics that are similar across a variety of stigmatized health conditions in very diverse cultures.

CONCLUSION

A more generic approach to the study of health-related stigma opens up important practical opportunities - cross-cutting measurement and intervention tools are resource saving and easier to use for personnel working with multiple conditions, allow for comparison between conditions, and recognize the intersectionality of many types of stigma. Further research is needed to build additional evidence demonstrating the advantages and effectiveness of cross-condition approaches to stigma measurement and interventions.

Internalized stigma and its impact in Indian outpatients with bipolar disorder

Patients with many psychiatric disorders have considerable internalized stigma. The current study intended to examine the level and impact of internalized stigma in patients with bipolar affective disorder (BPAD). 60 patients with BPAD, 33 patients with schizophrenia and 30 patients with anxiety disorders were compared on Internalized Stigma of Mental Illness scale and The Stigma Scale. The patients with BPAD were assessed using Rosenberg Self-Esteem Scale (RSES), Participation scale (PS) and World Health Organization Quality Of Life - Brief Version - Hindi (WHOQOL-bref). Significant differences were found in all domains of self-stigma measures among the three groups. Using appropriate covariates, it was found that the differences were significant and independent of the effect of the covariates. In patients of BPAD, stigma and its domains were significantly correlated with the measures on monthly income, education, socio-occupational functioning, RSES, PS and WHOQOL-bref. Patients with BPAD experience substantial stigma, which was intermediate between that experienced by patients with schizophrenia (higher) and that experienced by patients with anxiety disorder (lower). Internalized stigma has significant impact on self-esteem, socio-occupational participation and functioning, and quality of life in patients with BPAD. Small sample size, sample of convenience, and cross-sectional design, limit the generalizability of the results.

Stigma experienced by patients with severe mental disorders: A nationwide multicentric study from India

This study aimed to evaluate the stigma and its correlates among patients with severe mental disorders. Patients with diagnosis of schizophrenia (N = 707), bipolar disorder (N = 344) and recurrent depressive disorder (N = 352) currently in clinical remission from 14 participating centres were assessed on Internalized Stigma of Mental Illness Scale (ISMIS). Patients with diagnosis of schizophrenia experienced higher level of alienation, sterotype endorsement, discrimination experience and total stigma when compared to patients with bipolar disorder and recurrent depressive disorder. Patients with bipolar disorder experienced higher stigma than those with recurrent depressive disorder in the domain of stigma resistance only. Overall compared to affective disorder groups, higher proportion of patients with schizophrenia reported stigma in all the domains of ISMIS. In general in all the 3 diagnostic groups' stigma was associated with shorter duration of illness, shorter duration of treatment and younger age of onset. To conclude, this study suggests that compared to affective disorder, patients with schizophrenia experience higher self stigma. Higher level of stigma is experienced during the early phase of illness. Stigma intervention programs must focus on patients during the initial phase of illness in order to reduce the negative consequences of stigma.

Concordance of the Indian Mental Healthcare Act 2017 with the World Health Organization's Checklist on Mental Health Legislation

BACKGROUND

India is revising its mental health legislation with the Indian Mental Healthcare Act 2017 (IMHA). When implemented, this legislation will apply to over 1.25 billion people. In 2005, the World Health Organization (WHO) published a Resource Book (WHO-RB) on mental health, human rights and legislation, including a checklist of 175 specific items to be addressed in mental health legislation or policy in individual countries. Even following the publication of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) (2006), the WHO-RB remains the most comprehensive checklist for mental health legislation available, rooted in UN and WHO documents and providing the most systematic, detailed framework for human rights analysis of mental health legislation. We sought to determine the extent to which the IMHA will bring Indian legislation in line with the WHO-RB.

METHODS

The IMHA and other relevant pieces of Indian legislation are compared to each of the items in the WHO-RB. We classify each item in a binary manner, as either concordant or not, and provide more nuanced detail in the text.

RESULTS

The IMHA addresses 96/175 (55.4%) of the WHO-RB standards examined. When other relevant Indian legislation is taken into account, 118/175 (68.0%) of the standards are addressed in Indian law. Important areas of low concordance include the rights of families and carers, competence and guardianship, non-protesting patients and involuntary community treatment. The important legal constructs of advance directives, supported decision-making and nominated representatives are articulated in the Indian legislation and explored in this paper.

CONCLUSIONS

In theory, the IMHA is a highly progressive piece of legislation, especially when compared to legislation in other jurisdictions subject to similar analysis. Along with the Indian Rights of Persons with Disabilities Act 2016, it will bring Indian law closely in line with the WHO-RB. Vague, opaque language is however, used in certain contentious areas; this may represent arrangement-focused rather than realisation-focused legislation, and lead to inadvertent limitation of certain rights. Finally, the WHO-RB checklist is an extremely useful tool for this kind of analysis; we recommend it is updated to reflect the CRPD and other relevant developments.

Recovery and its correlates among patients with bipolar disorder: A study from a tertiary care centre in North India

BACKGROUND AND AIM

The goal of treatment in mental illness has evolved from a symptom-based approach to a personal recovery-based approach. The aim of this study was to evaluate the predictors of personal recovery among patients with bipolar disorder.

METHODOLOGY

A total of 185 patients with bipolar disorder, currently in remission, were evaluated on Recovery Assessment Scale (RAS), Internalized Stigma of Mental Illness Scale (ISMIS), Brief Religious coping scale (RCOPE), Duke University Religiosity Index (DUREL), Religiousness Measures Scale, Hamilton depression rating scale (HDRS), Young Mania rating scale (YMRS) and Global Assessment of Functioning (GAF) scale.

RESULTS

The mean age of the sample was 40.5 (standard deviation (SD), 11.26) years. Majority of the participants were male, married, working, Hindu by religion and belonged to extended/joint families of urban background. In the regression analysis, RAS scores were predicted significantly by discrimination experience, stereotype endorsement and alienation domains of ISMIS, level of functioning as assessed by GAF, residual depressive symptoms as assessed by HDRS and occupational status. The level of variance explained for total RAS score and various RAS domains ranged from 36.2% to 46.9%.

CONCLUSION

This study suggests that personal recovery among patients with bipolar disorder is affected by stigma, level of functioning, residual depressive symptoms and employment status of patients with bipolar disorder.