Common sense model of mental illness: Understanding the impact of cognitive and emotional representations of mental illness on recovery through the mediation of self-stigma

Latent Profile Analysis of Self-Stigma Among Individuals With Schizophrenia and Its Relationship With Illness Perception

PURPOSE

To investigate self-stigma among individuals with schizophrenia, identify potential categories of self-stigma, and analyze the association between self-stigma categories and dimensions of disease perception.

METHOD

Convenience sampling was used to select individuals with schizophrenia (N = 216) in psychiatric hospitals. A General Demographic Information Questionnaire, the Internalized Stigma of Mental Illness Inventory, and Brief Illness Perception Questionnaire were used for data collection. A latent profile analysis was performed on self-stigma characteristics of participants, and potential categories of influencing factors and their relationship with illness perception were examined.

RESULTS

Participants were classified into three potential categories: low self-stigma-low resistance (19.4%), medium self-stigma (55.6%), and high self-stigma-high discrimination (25%). Compared with the low self-stigma-low resistance group, those with higher illness representation and illness understanding scores were more likely to be classified as medium self-stigma, and emotional representation was the strongest predictor for high self-stigma-high discrimination.

CONCLUSION

Self-stigma among participants was mostly medium to high. Self-stigma of individuals with schizophrenia demonstrates group heterogeneity; therefore, nurses should formulate targeted interventions based on the characteristics of each category to achieve precise interventions and reduce self-stigma. [Journal of Psychosocial Nursing and Mental Health Services, xx(xx), xx-xx.].

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.

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.

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.

Feasibility and Preliminary Efficacy of a Community-Based Addiction Rehabilitation Electronic System in Substance Use Disorder: Pilot Randomized Controlled Trial

BACKGROUND

Drug use disorder has high potential for relapse and imposes an enormous burden on public health in China. Since the promulgation of the Anti-drug law in 2008, community-based rehabilitation has become the primary approach to treat drug addiction. However, multiple problems occurred in the implementation process, leading to a low detoxification rate in the community. Mobile health (mHealth) serves as a promising tool to improve the effectiveness and efficiency of community-based rehabilitation. Community-based addiction rehabilitation electronic system (CAREs) is an interactive system for drug users and their assigned social workers.

OBJECTIVE

The study aimed to examine the feasibility and preliminary efficacy of CAREs in community-based rehabilitation from the perspective of drug users and social workers in Shanghai, China.

METHODS

In this pilot randomized controlled trial, 40 participants were recruited from the community in Shanghai from January to May 2019. Participants randomized to the intervention group (n=20) received CAREs + community-based rehabilitation, while participants in the control group (n=20) received community-based rehabilitation only for 6 months. CAREs provided education, assessment, and SOS (support) functions for drug users. The assigned social workers provided service and monitored drug use behavior as usual except that the social workers in the intervention group could access the webpage end to obtain drug users' information and fit their routine workflow into CAREs. The primary outcome was the feasibility of CAREs, reflected in the overall proportion and frequency of CAREs features used in both app and webpage end. The secondary outcomes were the effectiveness of CAREs, including the percentage of drug-positive samples, longest period of abstinence, contact times with social workers, and the change of Addiction Severity Index (ASI) from baseline to the 6-month follow-up.

RESULTS

The number of participants logged in to the app ranged from 7 to 20 per week, and CAREs had relatively high levels of continued patient use. Drug users preferred assessment and education features in the app end while their social workers showed high levels of use in urine results record and viewing assessment results on the webpage end. After the 6-month intervention, 3.3% (17/520) of samples in the intervention group and 7.5% (39/520) in the control group were drug-positive (F=4.358, P=.04). No significant differences were noted between the control and intervention groups in terms of longest duration of abstinence, number of contact times and ASI composite scores.

CONCLUSIONS

The study preliminarily demonstrated that with relatively good feasibility and acceptability, CAREs may improve the effectiveness and efficiency of the community-based rehabilitation, which provided instruction for further improvement of the system.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03451344; https://clinicaltrials.gov/ct2/show/NCT03451344.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.3389/fpsyt.2018.00556.

Can psychological flexibility and prosociality mitigate illness perceptions toward COVID-19 on mental health? A cross-sectional study among Hong Kong adults

BACKGROUND

The negative impact of COVID-19 pandemic on public mental health can be persistent and substantial over a long period of time, but little is known regarding what psychological factors or processes can buffer such impact. The present study aimed to examine the mediating roles of coping, psychological flexibility and prosociality in the impacts of perceived illness threats toward COVID-19 on mental health.

METHOD

Five-hundred and fourteen Hong Kong citizens (18 years or above) completed an online survey to measure illness perceptions toward COVID-19, coping, psychological flexibility, prosociality, and mental health, together with their socio-demographic variables. Structural equation modelling was used to explore the explanatory model that was the best-fit to illustrate the relationships between these constructs.

RESULTS

Serial mediation structural equation model showed that only psychological flexibility (unstandardised beta coefficient, β = - 0.12, 95% CI [- 0.20, - 0.02], p = 0.031) and prosociality (unstandardised β = 0.04, 95% CI [0.01, 0.08], p = 0.001) fully mediated the relationship between illness perceptions toward COVID-19 and mental health. In addition, psychological flexibility exerted a direct effect on prosociality (standardised β = 0.22, 95% CI [0.12, 0.32], p < 0.001). This best-fit model explained 62% of the variance of mental health.

CONCLUSIONS

Fostering psychological flexibility and prosocial behaviour may play significant roles in mitigating the adverse effects of COVID-19 and its perceived threats on public mental health.

Using Network Theory for Psychoeducation in Eating Disorders

Background

Negative illness representations such as self-blame impede treatment-seeking behavior and therapy motivation in individuals with eating disorders (EDs). However, only one study so far has investigated how different explanatory models influence these beliefs in EDs. We aimed to expand these findings by introducing an explanatory model based on network theory (NT).

Methods

We presented three explanatory models to a diverse web-recruited sample (n = 290, 141 females, 149 males) with clinically elevated ED symptomatology. Participants either watched a video with a biological-genetic (BG), cognitive-behavioral (CB) or an NT explanatory model and were asked about illness representations before and after watching the video.

Results

The BG group showed significantly greater reductions in self-blame but a significant decrease in personal control and less optimistic expectation regarding timeline compared to the CB and NT groups. There were no group differences regarding the perception of the clinician, comprehensibility of the explanatory model and credibility of a CBT intervention.

Conclusions

Given the increasing popularity of biological-genetic explanatory models of EDs, it is important to note the disadvantages we found to be associated with these models. Our findings indicate that explanatory models emphasizing cognitive-behavioral (CB) principles and/or network theoretical (NT) underpinnings of EDs may serve to promote optimism and greater perceptions of personal agency in affected populations.

This trial's registration number is 316.

Awareness and Potential Impacts of the Medicalization of Internet Gaming Disorder: Cross-sectional Survey Among Adolescents in China

Background

The Eleventh Revision of International Classification of Diseases (ICD-11) newly listed gaming disorder, including internet gaming disorder (IGD), as a disease. The level of awareness and potential positive and negative impacts of this medicalization among adolescents were unknown.

Objective

This study investigated the levels, associated factors, and potential positive and negative impacts of awareness of the medicalization of IGD among adolescents in China.

Methods

In a cross-sectional survey, 1343 middle school students in Guangzhou, China, self-administered an anonymous questionnaire in classrooms (October to December 2019). Three risk subgroups were identified: those who scored ≥5 items in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition checklist (IGD-S), those who self-perceived having IGD currently (IGD-PC), and those who self-perceived having IGD within 12 months (IGD-P12M).

Results

Of the internet gamers, 48.3% (460/952) were aware of the medicalization of IGD; they were more likely to belong to the IGD-P12M/IGD-S risk subgroups. Within the IGD-PC/IGD-P12M (but not IGD-S) risk subgroups, IGD medicalization awareness was positively associated with favorable outcomes (reduced internet gaming time in the past 12 months, seeking help from professionals if having IGD, and fewer maladaptive cognitions). After being briefed about the ICD-11 inclusion of IGD, 54.2% (516/952) and 32.8% (312/952) expressed that it would lead to the reduction of gaming time and help-seeking behaviors, respectively; however, 17.9% (170/952), 21.5% (205/952), 15.9% (151/952), and 14.5% (138/952) perceived self-doubt for being diseased, stronger pressure from family members, negative emotional responses, and labeling effect, respectively. With a few exceptions, such perceived positive or negative impacts were stronger among the IGD-S, IGD-PC, and IGD-P12M risk subgroups.

Conclusions

The exploratory study shows that the medicalization of IGD may have benefits that need maximization and potentially harmful effects that need minimization. Future studies should test the efficacies of health promotion that increases IGD medicalization awareness.

Assessment of illness representations in mental disorders: A mini review

Health beliefs, and especially illness representations, have been widely used to understand clinical outcomes and psychosocial adjustment in people with physical diseases. However, this area of research has been under-explored in the field of mental health, and the few studies that have been conducted have used very different methods. Therefore, the aim of our study was to identify the tools and methods that have been used to evaluate illness representations in psychiatry. To this end, a mini review has been conducted and 58 articles were retained. This mini review highlights that the quantitative method is the most used, and that the scales mobilised are often adapted for the study, but not validated. Indeed, multiple modifications and adaptations have been made by the authors (e.g. deletion of subscales, addition of items), which lead to questions about the reliability of what is measured. In the future, it is essential to have a validated generic tool for mental disorders, which could be based on the Illness perceptions questionnaire for schizophrenia.

Relationship Between Illness Representations, Psychosocial Adjustment, and Treatment Outcomes in Mental Disorders: A Mini Review

Understanding and improving the psychosocial adjustments (e.g., quality of life, depression) and treatment outcomes (e.g., adherence, beliefs about treatments) of people with mental disorders are major health issues. The self-regulation model (SRM) postulates that illness representations play a central role on adjustment and treatment of people with physical illnesses. Recently, the SRM has been used with people with mental disorders. However, the manifestations of somatic and psychiatric disorders can be very different. Therefore, the use of SRM in the field of mental health is very complex. This difficulty, as well as the growing interest for illness representations in the field of mental health, justifies the utility to conduct a review on this topic. The current review shows that illness representations are related to psychosocial adjustment and/or treatment outcomes for people with various mental disorders [e.g., psychotic disorders, mood disorder, posttraumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD)]. However, some limitations to the applicability of SRM to mental disorders have been highlighted. These limitations should be considered in future studies.

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

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

Cognitive, Regulatory, and Interpersonal Mechanisms of HIV Stigma on the Mental and Social Health of Men Who Have Sex With Men Living With HIV

Public stigma surrounding HIV is related to heightened emotional distress, poor psychological functioning, and reduced subjective well-being in people living with HIV. For men who have sex with men (MSM) living with HIV, they may also face stigmatizing attitudes within the gay community, which create an additional burden to their health. Grounded in the psychological mediation framework, the present study examined the underlying psychological processes through which HIV stigma from the public and within the gay community influences the mental and social health of MSM living with HIV. Findings from 206 Chinese MSM living with HIV in Hong Kong indicated that negative self-concept, maladaptive coping, and peer isolation mediated the effect of HIV stigma on mental and social health. The study revealed the cognitive, regulatory, and interpersonal processes underlying HIV stigma and health. Feeling intense HIV stigma from the public and within the gay community may render MSM living with HIV more vulnerable to negative self-concept, maladaptive coping, and peer isolation, which contribute to poor mental and social health. To combat prejudice and discrimination against people living HIV, stigma reduction initiatives should be implemented not only in the public, but also in the gay community. Cognitive-behavioral interventions can also be used to restructure negative self-beliefs and build adaptive emotion regulation skills, which can improve stigma-related health outcomes among MSM living with HIV.

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

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

Modeling variables associated with personal recovery among service users with mental disorders using community-based services

BACKGROUND

Mental health research is evolving toward the identification of conceptual models and associated variables, which may provide a better understanding of personal recovery, given its importance for individuals affected by mental disorders (MDs).

AIMS

This article evaluated personal recovery in a sample of adults with MDs using an adapted conceptual framework based on the Andersen behavioral model, which evaluates predisposing, enabling and needs factors in service use.

METHODS

The study design was cross-sectional and included 327 mental health service users recruited across four local health service networks in Quebec (Canada). Data were collected using seven standardized instruments and participant medical records. Structural equation modeling was performed.

RESULTS

Quality of life (QOL), an enabling factor, was most strongly associated with personal recovery. Health behavior variables associated with recovery included the following: use of alcohol services, having a family physician, consulting a psychologist, use of food banks, consulting fewer professionals and not using drug services. Regarding needs factors, higher numbers of needs, lower severity of unmet health, social and basic needs and absence of mood disorders were also associated with personal recovery. No predisposing factors emerged as significant in the model.

CONCLUSION

Findings suggest that QOL, needs variables and comprehensive service delivery are important in personal recovery. Services should be individualized to the health, social and basic needs of service users, particularly those with mood disorders or co-occurring mental health/substance use disorders.

Development and validation of Attitudes towards Recovery Questionnaire across Chinese people in recovery, their family carers, and service providers in Hong Kong

Considering the lack of existing measures on attitudes toward personal recovery and the need to acknowledge the cultural milieu in recovery attitude assessment, the present study developed and validated the Attitudes towards Recovery Questionnaire (ARQ) in a sample of people in recovery of mental illness, family carers, and mental health service providers in Hong Kong. The ARQ was developed based on existing literature and measures of recovery, and focus group discussions with various stakeholders. Findings of the multi-sample confirmatory factor analyses supported a five-factor structure: (1) resilience as a person in recovery, (2) self-appreciation and development, (3) self-direction, (4) family involvement, and (5) social ties and integration. The ARQ was positively correlated with recovery outcomes, empowerment, recovery knowledge, and recovery orientation of mental health services. As a tool for examining recovery attitudes, the ARQ informs us of the mindset across stakeholders and areas that need enhancement to facilitate the recovery process.

Feasibility of a Mobile Phone App to Support Recovery From Addiction in China: Secondary Analysis of a Pilot Study

Background

Mobile health technologies have been found to improve the self-management of chronic diseases. However, there is limited research regarding their feasibility in supporting recovery from substance use disorders (SUDs) in China.

Objective

The objective of this study was to examine the feasibility of a mobile phone-based ecological momentary assessment (EMA) app by testing the concordance of drug use assessed by the EMA, urine testing, and a life experience timeline (LET) assessment.

Methods

A total of 75 participants dependent on heroin or amphetamine-type stimulant (ATS) in Shanghai were recruited to participate in a 4-week pilot study. Of the participants, 50 (67% [50/75]) were randomly assigned to the experimental group and 25 (33% [25/75]) were assigned to the control group. The experimental group used mobile health (mHealth) based EMA technology to assess their daily drug use in natural environments and received 2 short health messages each day, whereas the control group only received 2 short health messages each day from the app. Urine tests and LET assessments were conducted each week and a post-intervention survey was administered to both groups. The correlations among the EMA, the LET assessment, and the urine test were investigated.

Results

The mean age of the participants was 41.6 (SD 8.0) years, and 71% (53/75) were male. During the 4 weeks of observation, 690 daily EMA survey data were recorded, with a response rate of 49.29% (690/1400). With respect to drug use, the percent of agreement between the EMA and the LET was 66.7%, 79.2%, 72.4%, and 85.8%, respectively, for each of the 4 weeks, whereas the percent of agreement between the EMA and the urine test was 51.2%, 65.1%, 61.9%, and 71.5%, respectively. The post-intervention survey indicated that 46% (32/70) of the participants preferred face-to-face interviews rather than the mHealth app.

Conclusions

This study demonstrated poor agreement between the EMA data and the LET and found that the acceptance of mHealth among individuals with SUDs in China was not positive. Hence, greater efforts are needed to improve the feasibility of mHealth in China.