Toward understanding the insight paradox: internalized stigma moderates the association between insight and social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders

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.

Perceived Stigma Toward Cognitive Impairment Among People With Schizophrenia

OBJECTIVE

Stigma toward schizophrenia spectrum disorders is pervasive and negatively influences service access and delivery. Cognitive impairment associated with schizophrenia (CIAS) is common, but its association with stigma is unknown. In this study, the authors examined whether individuals with CIAS receiving cognitive remediation treatment report experiencing CIAS-related stigma and sought to establish associations between CIAS-related stigma and recovery-relevant outcomes.

METHODS

Data from 48 individuals with schizophrenia spectrum diagnoses were drawn from a larger study evaluating cognitive remediation. Participants completed measures of CIAS-related stigma, internalized mental illness stigma, self-perceived cognitive impairment, cognitive performance, and interviewer-rated quality of life.

RESULTS

CIAS-related stigma was commonly reported and significantly positively associated with internalized stigma and self-perceived cognitive impairment. CIAS-related stigma was also significantly negatively associated with motivation to engage in goal-directed behavior and daily activities.

CONCLUSIONS

CIAS-related stigma exists and warrants additional exploration with regard to implications for psychiatric service delivery.

Systematic review and meta-analysis of internalised stigma and stigma resistance in patients with psychosis: The impact of individualism-collectivism culture and other individual factors

PURPOSE

This study aimed to meta-analysis the level of internalised stigma experienced by individuals with psychosis worldwide, and the impact of cultural differences, economic status of the studied regions and duration of illness on their levels of internalised stigma. Clinical and individual level factors associated with internalised stigma and stigma resistance were also systematically reviewed.

METHODS

A systematic search of keywords on two scholarly databases were conducted. The individualism index of the countries or regions where the studies were conducted was retrieved from Hofstede's updated measurement of individualism. Economic status of regions was categorised based on their per capita gross national income. Meta-analysis and meta-regression were conducted using the 'metafor' package in R. Factors associated with internalised stigma and stigma resistance were also systematically consolidated.

RESULTS

Seventy-three articles were included in the meta-analysis and the pooled score of both internalised stigma and stigma resistance of individuals with psychosis were within the mild range (2.20 and 2.44, respectively). The meta-regression analysis found high collectivism culture is significantly related to a higher level of internalised stigma. Economic status was not significant. Thirty-five articles were included in the systematic review and clinical, psychological, psychosocial variables, cognition and sociodemographic factors were found to be associated with internalised stigma.

CONCLUSION

Internalised stigma in psychosis is ubiquitous worldwide and high collectivism culture may be related with high internalised stigma. With the presence of multiple individual factors related to internalised stigma, intervention programmes to reduce internalised stigma should consider focussing on both macro- and micro-level factors.

Confronting mental health stigma in Haitian Americans suffering from mental health challenges

BACKGROUND

Haitian Americans have been disproportionately exposed to risk factors known to play a significant role in the development of mental illness. Yet despite the documented effectiveness of mental health treatment, a high proportion of Haitian Americans with mental health disorders have not received care.

LOCAL PROBLEM

Internalized stigma of mental illness (ISMI) was reported as one of the primary reasons Haitian Americans do not seek help for mental illnesses, resulting in poor long-term outcomes for individuals and families in this community. This quality improvement project characterized ISMI among Haitian Americans, examined associated demographic factors, and tested the impact of a culturally relevant ISMI educational video intervention on willingness to seek mental health treatment.

METHODS

Haitian Americans who self-reported mental illness ( N = 20) were recruited from a South Florida clinic. Descriptive statistics, correlations, and thematic analyses were completed to analyze the data.

INTERVENTIONS

Participants completed the nine-item ISMI scale, watched an educational video about ISMI, completed a post-intervention survey, and engaged in conversations about mental health and ISMI.

RESULTS

Sixty-five percent of participants reported mild levels of ISMI. Sex was significantly correlated with ISMI ( r = -0.458, p = .042); male participants experienced higher levels of ISMI. The educational video improved participants' knowledge of ISMI, and 85% indicated increased willingness to seek treatment.

CONCLUSIONS

When caring for Haitian Americans with mental illnesses, nurse practitioners should initiate conversations about ISMI, consider gender differences in mental illness beliefs and attitudes, and provide culturally responsive psychoeducational interventions to promote more mental health treatment utilization.

The Relationship Between Internalized Stigma with Self-reported Cognitive Dysfunction and Insight in Schizophrenia

Background

This study aimed to evaluate the relationship between internalized stigma with self-reported cognitive dysfunction and insight in individuals with schizophrenia.

Methods

There were 69 patients diagnosed with schizophrenia in the study. Severity of illness, insight, self-reported cognitive impairment, and internalized stigma were assessed using the Positive and Negative Syndrome Scale, the Schedule for the Assessment of Insight (SAI), the Schizophrenia Cognition Rating Scale (SCoRS), and the Internalized Stigma of Mental Illness (ISMI) scale.

Results

Schizophrenia Cognition Rating Scale-patient scores correlated positively and significantly with the ISMI subscales Alienation and Stereotype Endorsement. Schedule for the Assessment of Insight scores correlated positively and significantly with the ISMI subscales Alienation, Stereotype Endorsement, Discrimination Experience, and Social Withdrawal. There was no correlation between SCoRS-patient, SAI subscale, and total scores. In the regression analysis, SCoRS-patient score and SAI total scores explained 38.2% of the ISMI Alienation subscale, and 25.5% of the ISMI Stereotype Endorsement subscale.

Conclusion

Significant associations were found between internalized stigma with self-reported cognitive impairment and insight. Clinicians should be aware of higher degrees of internalized stigma in persons with schizophrenia who experience subjective cognitive deficits and have higher levels of insight.

The Mediating and Moderating Role of Resilience Between Stigma and Illness Identity Among People with Inflammatory Bowel Disease

Background

Stigma is assumed to lead to negative illness identity in one who got chronic illness, and there is a lack of understanding regarding the underly mechanisms. However, no research has examined the extent to which stigma was associated with illness identity in people with IBD. Therefore, we investigated the relationship between stigma and illness identity, specifically to examine whether resilience mediated or moderated the relationship.

Methods

A cross-sectional study was performed among patients diagnosed with inflammatory bowel disease from three tertiary hospitals in Jiangsu Province, China. Measurement instruments included the Stigma Scale for Chronic Illness (SSCI), the Resilience Scale for Patients with Inflammatory Bowel Disease (RS-IBD), and the Illness Identity questionnaire (IIQ). Mediation and moderated mediation analyses were conducted.

Results

A total of 322 patients with IBD were involved in the current study. We observed that there was a strong connection between stigma and rejection and engulfment. Moreover, resilience played a partial or complete mediating role in stigma and engulfment, acceptance and enrichment, and resilience moderates the relationship between stigma and rejection.

Conclusion

The current study examined whether resilience mediated or moderated the relationship between stigma and illness identity. These finding add to the theoretical basis of how stigma influences illness identity and help guide the resilience into engulfment reduction programs for IBD.

Measurement of perceived pressures in psychiatry: paper-and-pencil and computerized adaptive version of the P-PSY35 scale

PURPOSE

Formal coercion in psychiatry is widely studied yet much less is known about pressures patients may experience, partly because of the very few measures available. The goal of this study was to validate the P-PSY35 (Pressures in Psychiatry Scale) and provide a paper-and-pencil and a computerised adaptive test (CAT) to measure pressures experienced by patients in psychiatry.

METHODS

The P-PSY35 items were developed with users. Patients were evaluated during psychiatric hospitalisation or through an online survey. Mokken scale analysis and Item response theory (IRT) were used to select and estimate the items parameters. A Monte-Carlo simulation was performed to evaluate the number of items needed to transform the paper-and-pencil test into a reliable psychometric CAT.

RESULTS

A total of 274 patients were assessed. The P-PSY35 demonstrated good internal validity, internal consistency, convergent and divergent validity. The P-PSY35 could be substantially shortened while maintaining excellent reliability using the CAT procedure.

CONCLUSION

The P-PSY35 was developed in collaboration with users. It is a psychometrically rigorous tool designed to measure experienced pressures in French-language. The development and successful validation of the P-PSY35 represent a welcome step towards implementing and evaluating programs aimed at reducing negative consequences of coercion.

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.

Information gathered through draws-to-decision, social functioning, and personal recovery among patients with schizophrenia in Japan

INTRODUCTION

In schizophrenia, social functioning and personal recovery are pivotal outcomes potentially influenced by cognitive biases such as Jumping to Conclusions (JTC). Despite their significance, the relationship between JTC, social functioning, and personal recovery remains unclear. This study aims to investigate this relationship to inform tailored interventions for schizophrenia management.

METHODS

Data were collected from 94 schizophrenia patients using standardised measures. The Beads Task assessed JTC, whereas the Brief PANSS, TMT-J, SLOF-J, and RAS-J evaluated psychiatric symptoms, neurocognitive functioning, social functioning, and personal recovery, respectively. Statistical analyses included correlation and hierarchical regression.

RESULTS

Correlation analyses revealed a significant negative correlation between JTC and personal recovery (r = -0.27, p < 0.05). Hierarchical regression indicated JTC as a significant negative predictor of personal recovery (β = -0.33, p = 0.01). No significant correlation was found between JTC and social functioning.

DISCUSSION

Increased JTC was associated with lower levels of personal recovery in schizophrenia patients, independent of demographic and clinical factors. In the case of individuals with schizophrenia who demonstrate JTC, there is a potential to suggest the paradox of insight or apparent personal recovery scores.

Predictive factors for acceptance of a long-acting opiate substitution treatment studied through social representations and internalized stigma

OBJECTIVES

Opioid use disorder is a public health problem worldwide with a treatment gap partially due to sociocultural representation and stigma. Taking the opportunity of an authorization to a subcutaneous (SC) injectable solution of buprenorphine, the first and only injectable treatment for opioid dependence available in France, we investigate potential obstacles to its implementation in France.

METHODS

This study aimed to define the factors predicting the acceptance of a new SC form of opiate substitution treatment (OST) by comparing the social representations using an adapted version of the Explanatory Model Interview Catalogue (EMIC) and the internalized stigma of intravenous drug injection using the Internalized Stigma of Mental Illness Inventory (ISMI) between participants receiving OST likely to accept the SC form or not. We also observed whether the fear of an opiate withdrawal syndrome could influence this choice.

RESULTS

Fifty OST patients were included, 54% of them accepted a new SC form of OST. Perceived causes of drug injection measured with EMIC were significantly lower among participants who would not accept the new SC form. No significant difference was found regarding the total score of the adapted ISMI or its items. The fear of opiate withdrawal syndrome did not seem to be statistically related to acceptance of a long-acting SC OST in either group. The most discriminating combination of factors in predicting patient acceptance of such treatment was related to the perceived causes of drug injection associated with a severe Diagnostic and Statistical Manual of Mental Disorders 5th version (DSM-5) diagnosis, and a lower alcohol consumption.

CONCLUSIONS

We observed significant differences in social representations but not in internalized stigma between the two groups. Moreover, the predictive factors linked to the acceptance of a new SC form of OST suggest a multifactorial combination of elements that will have to be tested in a larger and prospective study delivering long-acting high-dose buprenorphine.

Treatment-seeking threshold and accessibility of psychiatric outpatient services in Switzerland: the relationship with stigma and self-esteem

Perceived stigmatization and low self-esteem are linked to poorer mental health outcomes, but their impact on treatment-seeking thresholds and the importance of outpatient service location remain unclear. The study included 525 outpatients of the University Psychiatric Clinic (UPK) Basel, Switzerland, of whom 346 were treated at inner city services and 179 at services located on the main site of the UPK at the outer city limits. Perceived discrimination and devaluation (PDD), self-esteem (SE), treatment-seeking threshold (TST), and accessibility were measured via a self-reported questionnaire. The PDD consisted of 12 items evaluating beliefs about the level of stigma towards individuals with mental illness in the general population on a 5-point Likert scale. SE, TST and accessibility were assessed through single-item 7-point Likert scales. PDD and SE were positively correlated (p < 0.001), suggesting that lower perceived stigma was linked to higher self-esteem, and were not associated with TST. The relationship between PDD and SE remained consistent after controlling for age, gender, and nationality. Age was negatively correlated with TST (p = 0.022), while gender did not significantly influence any of the variables. There was little variation regarding PDD, with emergencies at the site of the psychiatric clinic and substance use disorder (SUD) patients reporting higher levels of stigmatization. Emergency patients and those with SUD and personality disorder reported the lowest SE ratings. TST showed a broad range and was highest for emergency services and transcultural psychiatry patients. Differences in accessibility were mainly linked to the location, with outpatient service users in the inner city reporting better accessibility (p < 0.001) and higher SE (p = 0.009). In comparison to patients using services with planned contacts only, patients in emergency settings differed by higher TST (p = 0.018) and better ratings of accessibility (p = 0.004). In conclusion, there was a relevant amount of stigmatization, impaired self-esteem, and, for some outpatient services, high thresholds to seek treatment. Future research should explore other factors influencing TST. The findings highlight the need to address stigmatization and accessibility when planning mental health services.

Demoralization in Schizophrenia: A Pathway to Suicidal Ideation?

INTRODUCTION

Individuals with schizophrenia are at increased risk for suicide, and the Demoralization Hypothesis states that non-delusional awareness of one's social, cognitive, or occupational deterioration elicits depression and hopelessness. Both depression and hopelessness are established risk factors for suicide and are features of schizophrenia. The present study investigated whether insight into one's schizophrenia yields suicidal ideation, specifically by way of thwarted belongingness and perceived burdensomeness, which are constructs related to demoralization and measured by the Interpersonal Needs Questionnaire (INQ).

METHODS

Three separate models explored the mediating role of INQ scores on suicidal ideation in 99 participants with schizophrenia. With suicidal ideation entered as the dependent variable and INQ scores entered as the mediator, the first model included insight as the independent variable, the second included cognitive functioning, and the third included cognitive deterioration post-illness-onset.

RESULTS

Consistent with our hypothesis, INQ scores related to suicidal ideation (B = .03, SE = .01, p < .001). However, neither insight, cognitive functioning, nor cognitive deterioration predicted INQ scores or suicidal ideation. Additionally, INQ scores did not mediate relationships with suicidal, ideation.

CONCLUSION

Although INQ scores led to increased suicidal ideation, neither insight into illness, current cognitive functioning, nor shift in functioning led to increased INQ scores. Implications are discussed, and future directions are proposed.

The impact of hope levels on treatment adherence in psychiatric patients

PURPOSE

In this study, aimed to determine the status of hope and treatment adherence in psychiatric patients and the relationship between the two.

MATERIAL AND METHOD

The sample of the study consisted of participants (n = 103) in a university hospital psychiatric clinic. Research data were collected using personal information form, Morisky treatment adherence scale and Herth Hope Index (HHI). Statistical analysis of the data was carried out with SPSS 22.0 program using descriptive tests, student t-test, one-way variance analysis, chi-square test and Spearman correlation analysis.

RESULTS

The average score of the patients' hope scale is 34.23 ± 9.59 and is above the intermediate level. 43.7 % of patients have low adherence with treatment. It was found that as patients' hope scores increased (r = -0.417) non-adherence with treatment decreased; as annual hospitalization increased non-adherence increased (r = 0.274); as the duration of disease increased score of hope (r = -0.271), non-adherence with therapy (r = 0.353) and annual hospitalization increased (r = 0.211) (p < .05). Among the patients who took part in the study, 36.9 % were diagnosed with bipolar disorder, 33.0 % with schizophrenia and other psychotic disorders, 20.4 % with depression. Patients with bipolar disorder had higher treatment non-adherence scores. It was determined that 29.1 % of the patients stopped taking medication thinking they had recovered and 28.2 % did not adhere to the treatment due to drug side effects.

CONCLUSION

The findings underscore the crucial role of hope in influencing treatment adherence among psychiatric patients. Clinicians should consider strategies to bolster hope as a potential avenue for improving adherence rates.

Self-esteem in children and adolescents with and without attention-deficit/hyperactivity disorder: A meta-analytic review

Meta-analytic methods were used to examine global and domain-specific (i.e., academic, social, behavioral) self-esteem in children and adolescents with and without ADHD. Potential moderators of effect size heterogeneity were also examined via meta-regressions within a three-level approach. Findings from 49 aggregated global self-esteem effect sizes (ADHDN = 2500, TDN = 9448), 12 academic self-esteem effect sizes (ADHDN = 386, TDN = 315), 11 social self-esteem effect sizes (ADHDN = 258, TDN = 254), and 8 behavioral self-esteem effect sizes (ADHDN = 231, TDN = 211) suggest that children and adolescents with ADHD experience moderate global (ES = 0.46, p < .001), academic (ES = 0.60, p = .009), and social (ES = 0.67, p = .001) self-esteem impairments compared to children and adolescents without the disorder. The aggregated behavioral self-esteem effect size (ES = 0.20, p = .54), however, was not significant, and the global self-esteem effect size was markedly smaller compared to effect sizes for the academic and social domains. Further, examination of potential moderators of effect size heterogeneity indicated null effects for medication status, diagnostic complexity, informant, age, sex, comorbid psychopathology, and self-esteem dimension. Collectively, findings suggest that children and adolescents with ADHD do not hold a ubiquitous negative self-perception of difficulties across academic, social, and behavioral domains of functioning, and unexamined domains that are distal to ADHD may serve to bolster global self-esteem.

Functioning, clinical severity, education and sex moderate the inverse relationship between insight and quality of life in patients with schizophrenia

BACKGROUND

In schizophrenia, insight, the recognition that one has a medical illness that requires treatment, has long been related to deteriorated quality of life, a phenomenon that has been described as the "insight paradox". Here, we aimed to determine whether certain socio-demographic and clinical characteristics strengthen or weaken this negative relationship.

METHODS

We used data from the French network of rehabilitation centers REHABase (N = 769). We explored mean differences in quality-of-life scores between patients with good insight vs. poor insight. We also explored modifying effects of socio-demographic and clinical characteristics (sex, education, age, functioning, clinical severity, duration of illness).

RESULTS

Patients with good insight had a decreased quality-of-life total score. Similar effects were found for the following sub-dimensions of quality of life: autonomy, physical and psychological well-being, and self-esteem. The negative effect of insight on quality of life was attenuated for people who had >12 years of education and for people with a higher level of functioning. By contrast, the negative effect of insight on quality of life was accentuated in people with greater clinical severity. Functioning and clinical severity showed similar modifying effects for other quality-of-life dimensions: autonomy, physical and psychological well-being, and self-esteem. Finally, males demonstrated an increased negative association between insight and self-esteem.

CONCLUSIONS

The relationship between insight and quality of life is moderated by socio-demographic and clinical circumstances. Future inquiries may utilize our findings by integrating socio-demographic and clinical factors in treatment programs designs to conjointly improve insight and quality of life.

Ultra-high risk for psychosis stigma: an updated Systematic Review

OBJECTIVE

To clarify if stigma associated with schizophrenia has also been directed towards the ultra-high risk for psychosis (UHR) population, the present review aimed at synthetizing the existing literature to update and extend our understanding on the topic.

METHODS

A systematic PRISMA-compliant review was performed in PubMed, Embase, Cochrane and Web of Science for articles published until 30/04/2023, using a combination of search terms describing the at-risk mental states for psychosis and stigma and correlated terms.

RESULTS

Thirty-eight studies were included. Twenty-nine addressed UHR individuals directly, and 9 conducted interviews with non-patients regarding UHR. A total of 2560 UHR individuals were assessed; mean sample size was of 88.3 participants. Most of the studies were quantitative non-randomized/observational with young adults, 71.4% used SIPS (Structured Interview for Psychosis-risk Syndromes) and 25.0% used CAARMS (Comprehensive Assessment of At-Risk Mental States). Overall, the summarized studies have mainly involved individuals already attending UHR clinics from Western and high income countries. Studies can be grouped into five forms of stigma, among which the most frequently explored was perceived public stigma, followed by public stigma, self-stigma/internalized stigma, stigma stress and associative stigma. The main study design was quantitative nonrandomized, with only one interventional study. Most of the results confirmed the presence of stigma toward UHR individuals and findings provide additional support to the fact that stigma seems to be present since the very early stages of the disease.

CONCLUSION

There is still a paucity of research and knowledge gaps about UHR-related stigma. Nevertheless, results suggest the presence of stigma toward UHR individuals, supporting the fact that stigma is present since the early stages of psychosis.

The co-construction and emotion management of hope within psychosis services

Introduction

There is a growing acknowledgement of the salience of hope for mental health service-users, in influencing care outcomes and recovery. Understandings of the processes through which hopes are co-constructed, alongside specific conceptualisations of experiences of hoping, remain limited however.

Methods

This qualitative study explored how a range of stakeholders experienced and dealt with uncertainty within three purposively selected psychosis services in southern England. In this article we focus particularly on the co-construction of hope within participants' narratives and how this emotion work shaped experiences of hoping. In-depth interviews (n = 23) with service-users, professionals, managers and other stakeholders were analysed following a phenomenological approach.

Findings

Hope was spontaneously identified by participants as a fundamental mechanism through which service-users and professionals managed uncertainty when vulnerable. Professionals were influential in shaping users' hopes, both intentionally and unwittingly, while some professionals also referred to managing their own hopes and those of colleagues. Such management of expectations and emotions enabled motivation and coping amidst uncertainty, for users and professionals, but also entailed difficulties where hope was undermined, exaggerated, or involved tensions between desires and expectations.

Discussion

Whereas, hope is usually reflected in the caring studies literature as distinctly positive, our findings point to a more ambivalent understanding of hope, as reflected in the accounts of both service-users and professionals where elevated hopes were described as unrealistic and harmful, to the well-being of professionals as well as of service-users. It is concluded that a greater awareness within care contexts of how hopes are co-constructed by professionals and service-users, explicitly and implicitly, can assist in improving health care and healthcare outcomes.

Psychosocial Correlates of Internalized Stigma Among Chinese Individuals With Severe Mental Illness

The current study aimed to examine internalized stigma and its psychosocial factors among people with severe mental illness in China. A cross-sectional study was performed with 202 adults diagnosed with schizophrenia, bipolar disorder, or schizoaffective disorder in Beijing, China. Participants were evaluated using the Chinese version of the Internalized Stigma of Mental Illness (ISMI) scale, Perceived Devaluation and Discrimination scale, and the Medical Outcomes Study Social Support Survey. Correlation analysis and multiple linear regression analysis demonstrated that 19.8% of participants had moderate-to-high ISMI scores, whereas the sample as a whole indicated a mild level of internalized stigma. A higher level of internalized stigma was associated with greater perceived discrimination, lower social support, lower family income, older age, and distancing coping. These factors may be important to consider for developing tailored interventions in the future. [Journal of Psychosocial Nursing and Mental Health Services, 62(1), 37-44.].

Making meaning of trauma in psychosis

Background

Finding new meaning and identity in the aftermath of trauma has been identified as a key process of mental health recovery. However, research indicates that this meaning-making process is compromised in people with psychosis. Considering the high prevalence, yet under-treatment of trauma in people with psychosis, it is urgent to gain insight into how their meaning-making process can be supported.

Aim

To gain insight into how people with psychosis make meaning of trauma and identify barriers and facilitators in their meaning-making process.

Methods

Qualitative inquiry of N = 21 interviews transcripts from the Dutch Psychiatry Storybank. We included interviews of people who (a) lived through multiple psychotic episodes, and (b) spontaneously addressed traumatic experiences in a low-structured interview. Storyline analysis was performed to gain insight into the meaning-making of trauma within their self-stories. Psychosocial conceptualizations of narrative identity were used to inform the analysis. A data-validation session with four experts-by-experience was organized to check and improve the quality of our analysis.

Results

We identified four different story types: (1) Psychiatry as the wrong setting to find meaning; (2) The ongoing struggle to get trauma-therapy; (3) Exposure to trauma as a threat to a stable life, and (4) Disclosure as the key to resolving alienation. Each story type comprises a different plot, meaning of trauma withing the self-story, (lack of) integration and barriers and facilitators in the meaning-making process. Overall, barriers in the meaning-making process were mostly situated within mental healthcare and stigma-related. People felt particularly hindered by pessimistic ideas on their capacity to develop self-insight and cope with distress, resulting in limited treatment options. Their process of adaptive meaning-making often started with supportive, non-judgmental relationships with individuals or communities that offered them the safety to disclose trauma and motivated them to engage in a process of self-inquiry and growth.

Conclusion

The outcomes illuminate the social context of the meaning-making challenges that people with psychosis face and illustrate the devastating influence of stigma. Our outcomes offer guidance to remove barriers to adaptive meaning-making in people with psychosis, and can help clinicians to attune to differences in the meaning-making of trauma.

The role of insight, social rank, mindfulness and self-compassion in depression following first episode psychosis

Gaining awareness of psychosis (i.e., insight) is linked to depression, particularly in the post-acute phase of psychosis. Informed by social rank theory, we examined whether the insight-depression relationship is explained by reduced social rank related to psychosis and whether self-compassion (including uncompassionate self-responding [UCS] and compassionate self-responding [CSR]) and mindfulness buffered the relationship between social rank and depression in individuals with first episode psychosis during the post-acute phase. Participants were 145 young people (Mage  = 20.81; female = 66) with first episode psychosis approaching discharge from an early psychosis intervention centre. Questionnaires and interviews assessed insight, depressive symptoms, perceived social rank, self-compassion, mindfulness and illness severity. Results showed that insight was not significantly associated to depression and thus no mediation analysis was conducted. However, lower perceived social rank was related to higher depression, and this relationship was moderated by self-compassion and, more specifically, UCS. Mindfulness was related to depression but had no moderating effect on social rank and depression. Results supported previous findings that depressive symptoms are common during the post-acute phase. The role of insight in depression for this sample is unclear and may be less important during the post-acute phase than previously considered. Supporting social rank theory, the results suggest that low perceived social rank contributes to depression, and reducing UCS may ameliorate this effect. UCS, social rank and possibly mindfulness may be valuable intervention targets for depression intervention and prevention efforts in the recovery of psychosis.

The association between outpatient continuation/maintenance electroconvulsive therapy, readmission risk and total direct cost in patients with depressive, bipolar and psychotic disorders: A naturalistic retrospective cohort study

BACKGROUND

The transdiagnostic effect of continuation/maintenance ECT (CM-ECT) across mood and psychotic disorders on hospital psychiatric readmission risk and total direct cost remains unclear.

METHODS

A naturalistic retrospective analysis of 540 patients who received inpatient acute ECT treatment from May 2017 to Mar 2021 in a tertiary psychiatric institution. Patients were assessed with validated clinical rating scales pre-ECT and after the first 6 treatments of a course of inpatient acute ECT. After discharge, patients who continued with CM-ECT were compared with those not receiving CM-ECT using survival analysis of hospital readmission. Total direct cost (hospitalisation and ECT treatment cost) was also analysed. All patients were subjected to a standard post-discharge monitoring program with case managers checking in on the patients regularly after discharge and ensuring they were given an outpatient appointment within a month of discharge.

RESULTS

Both cohorts had significant improvement in their rating scales scores after their first six 6 sessions of inpatient acute ECT. Patients who continued with CM-ECT after completing their inpatient acute ECT (mean number of acute ECT: N = 9.9, SD 5.3), had a significantly lower risk of readmission [adjusted hazard ratio of 0.68 (95 % CI: 0.49-0.94, p = 0.020)]. Patients who received CM-ECT also had a significantly lower average total direct cost compared to those who did not (SGD$35,259 vs SGD$61,337). For patients with mood disorders, the CM-ECT group had a significantly lower inpatient ECT cost, hospitalisation cost and total direct costs compared to those without CM-ECT.

LIMITATIONS

The naturalistic study cannot prove a causal relationship between CM-ECT and reduced readmission and lower healthcare costs.

CONCLUSION

CM-ECT is associated with lower readmission risks and lower total direct healthcare costs for the treatment of mood and psychotic disorders, especially for mood disorders.

Perceived Stress and Mental Health Literacy Among Chinese Preschool Teachers: A Moderated Mediation Model of Anxiety and Career Resilience

Purpose

Chinese public mental health is currently characterized by a high prevalence of mental ill health and a low consultation rate, due primarily to the nation's low mental health literacy. Previous studies have shown that occupational stress may be a risk factor for mental health literacy. In China, preschool teachers are under high pressure; however, few studies have examined the mechanisms that mediate and moderate the relationship between preschool teachers' feelings of stress and their mental health literacy.

Methods

A questionnaire was administered to 2352 preschool teachers to explore the relationship between their stress perceptions and mental health literacy.

Results

Preschool teachers' perceived stress was significantly and negatively associated with their mental health literacy, with anxiety playing a partially mediating role. Preschool teachers' career resilience moderated the relationship between perceived stress and anxiety. Perceived stress positively predicted anxiety for teachers with low levels of career resilience; for teachers with high levels of career resilience, perceived stress still positively predicted anxiety, and the higher the level of career resilience, the weaker the positive prediction of stress perception on anxiety.

Conclusion

Perceived stress directly predicted mental health literacy among preschool teachers, and also indirectly predicted mental health literacy through the mediating role of anxiety. Career resilience moderated the relationship between stress perception and anxiety. These findings provide new perspectives on the treatment and prevention of preschool teachers' mental ill health.

Stigma Experienced by Patients Who Recovered from COVID-19 in Post-Vaccination Period in Thailand; Prevalence and Associated Factors

Purpose

Social stigma related to coronavirus disease-2019 (COVID-19) has been a public concern since its emergence, especially in the patients who are reintegrating into their society. However, the insights into COVID-19 stigmatization after vaccine availability are limited. This study aimed to estimate the prevalence, severity and associated factors of stigma experienced by patients who recovered from COVID-19 and reintegrated into their communities. The insights gained from this study are not only beneficial to COVID-19 but can also be used as a background information in future epidemics.

Patients and Methods

This study consisted of two phases. The first phase involved the translation and validation of the COVID-19-related stigma questionnaire. The second phase was a questionnaire-based cross-sectional survey conducted between January and February 2022, at the Vajira Hospital, Bangkok, Thailand. A series of questionnaires regarding stigma, negative emotions (Depression Anxiety Stress Scale-21), and personal information were administered to COVID-19 patients who were already discharged and returned to their communities from June 2021 to February 28, 2022 (N = 354).

Results

The prevalence of stigma among the patients who recovered from COVID-19 was 57.9%. These were classified as mild (28.2%), moderate (21.5%), and severe (8.2%). Pearson's correlation analysis revealed that longer admissions (r = - 0.151, p = 0.001) and longer duration from discharge (r = - 0.222, p = 0.001) were related to lower stigma. Higher stigma was associated with higher levels of depression (r = 0.528, p <0.001), anxiety (r = 0.506, p <0.001) and stress (r = 0.583, p <0.001).

Conclusion

Social stigma related to COVID-19 in Thailand declined during the post-vaccination period. However, this issue did not disappear, and still took a toll on mental health. Our findings suggested that providing appropriate assessment and help to the patients who recovered from COVID-19 is essential, even in the post-vaccination period.

Improving Romantic Relationship Functioning Among Young Men With First-Episode Psychosis: Impact of a Novel Group Intervention

Previous research has highlighted many of the challenges faced by individuals with psychosis in romantic relationships. The present study aimed to evaluate the impact of a novel group intervention for men with first-episode psychosis (FEP) on dating success, romantic and sexual functioning, self-esteem, self-stigma, mentalizing skills, and symptomatology, while using a repeated single-case experimental design and comparing results across two treatment modalities (i.e., in-person or online). Twenty-seven participants from five treatment sites completed a 12-week group intervention. Qualitative data was also collected to assess participants' subjective experiences with the program. In both modalities, significant improvements were observed for romantic functioning, mentalizing skills, and symptomatology, with effect sizes ranging from small to large. Several participants also attended more dates and entered committed relationships after the intervention. Most participants were satisfied with the program and many felt that they had learned new skills and gained confidence in dating. Future research should replicate these findings in larger and more inclusive samples.

Sexual Well-Being in Individuals with Schizophrenia: A Pilot Study on the Role of Self-Esteem and Acceptance of Illness

Schizophrenia is one of the most severe chronic mental illnesses. It drastically changes an individual's life and well-being. Sexual well-being in schizophrenia is often sidelined, even though it is one of the main areas for maintaining quality of life. Based on the conservation of resources theory (COR) and empirical data, we assume that self-esteem and acceptance of illness help in coping with schizophrenia and maintaining sexual well-being. This pilot study aimed to determine the relationship between self-esteem, acceptance of illness, and sexual well-being in Polish individuals with schizophrenia. The results of 60 individuals were included in this study. In the present study, the Self-Esteem Scale (SES), Acceptance of Illness Scale (AIS), and Short Sexual Well-Being Scale (SSWBS) were used. The study showed a significant association between self-esteem, acceptance of illness, and sexual well-being. Self-esteem (β = 0.62) and acceptance of illness (β = 0.55) acted as positive and significant predictors of sexual well-being in individuals with schizophrenia. Acceptance of illness was also found to play a mediating role between self-esteem and sexual well-being in people with schizophrenia (indirect effect: β = 0.34; LLCI = 0.063; ULCI = 0.839). The current pilot study demonstrates the relationship between self-esteem, acceptance of illness, and sexual well-being. Our findings highlight the significant role of acceptance of illness in maintaining sexual well-being among individuals with schizophrenia.

Rate and correlates of self-stigma in adult patients with early psychosis

Introduction

Self-stigma impedes recovery process and is associated with poorer clinical and functional outcomes in people with psychotic disorders. However, there is limited research specifically examining self-stigma in the early stage of illness, and mixed findings were observed regarding factors associated with increased self-stigma. We aimed to investigate the rate and correlates of self-stigma in a cohort of adult patients with early psychosis using a comprehensive array of clinical, treatment and other illness-related variables.

Methods

A total of 101 Chinese adult early psychosis patients aged 26-55 years who had received three-year psychiatric treatment for first psychotic episode in Hong Kong and completed self-stigma assessment were included for the current investigation. A broad range of assessments encompassing socio-demographics, premorbid adjustment, onset and illness profiles, symptom severity, psychosocial functioning, treatment characteristics and medication side-effects were conducted.

Results

Twenty-eight (27.7%) patients had moderate-to-high levels of self-stigma. Univariate linear regression analyses showed that age at study entry, sex, educational level, age at psychosis onset, duration of untreated psychosis (DUP), insight level, global psychosocial functioning, and the use of second-generation antipsychotic were related to self-stigma levels. Final multivariable regression model revealed that female sex, younger age at entry, longer DUP and better insight were independently associated with higher levels of self-stigma.

Conclusion

More than one-fourth of early psychosis patients experienced significant self-stigma, highlighting an unmet need for early detection and intervention of self-stigma in the initial years of illness. Further investigation is warranted to clarify trajectories and predictors of self-stigma in the early illness course.

The paradoxical moderating effects of metacognition in the relationships between self-esteem, depressive symptoms, and quality of life in anorexia and bulimia

BACKGROUND

Self-esteem and depressive symptoms contribute to a lower quality of life in people suffering from eating disorders. However, limited research has examined whether other factors may affect how these variables influence one another over time. Metacognition is a previously unexplored determinant that may impact the relationships between self-esteem, depressive symptoms, and quality of life in instances of eating disorders.

AIM

This study sought to examine metacognitive self-reflectivity and mastery as moderators of the relationships between self-esteem, depressive symptoms, and quality of life and to determine if these relationships are different in people with anorexia compared with people with bulimia.

METHODS

Participants with anorexia (n=40) and bulimia (n=40) were recruited from outpatient clinics. The participants were assessed on their metacognitive ability and self-reported on measures to assess their depressive symptoms, self-esteem, and quality of life.

RESULTS

The results indicate that metacognitive self-reflectivity moderates the relationship between self-esteem, depressive symptoms, and quality of life in people with anorexia such that when self-reflectivity is high, lower self-esteem and higher depressive symptoms are associated with a lower quality of life. These relationships did not appear to be significant when self-reflectivity was low. In contrast, in the anorexia and bulimia groups, metacognitive mastery appeared to moderate the relationships between self-esteem, depressive symptoms, and quality of life such that when mastery was low, lower self-esteem and higher depressive symptoms were associated with a lower quality of life. These relationships did not appear significant when mastery was high.

CONCLUSION

Metacognitive self-reflectivity and mastery seem to play paradoxical moderating roles in the relationships between self-esteem, depressive symptoms, and quality of life in people with anorexia and bulimia. These findings pave the way toward further research and have important clinical implications.

Compassion-focused therapy (CFT) for the reduction of the self-stigma of mental disorders: the COMpassion for Psychiatric disorders, Autism and Self-Stigma (COMPASS) study protocol for a randomized controlled study

BACKGROUND

People with mental disorders face frequent stigmatizing attitudes and behaviors from others. Importantly, they can internalize such negative attitudes and thus self-stigmatize. Self-stigma is involved in diminished coping skills leading to social avoidance and difficulties in adhering to care. Reducing self-stigma and its emotional corollary, shame, is thus crucial to attenuate the negative outcomes associated with mental illness. Compassion-focused therapy (CFT) is a third-wave cognitive behavioral therapy that targets shame reduction and hostile self-to-self relationship and allows for symptom improvement while increasing self-compassion. Although shame is a prominent part of the concept of self-stigma, the efficacy of CFT has never been evaluated in individuals with high levels of self-stigma. The purpose of this study is to evaluate the efficacy and acceptability of a group-based CFT program on self-stigma, compared to a psychoeducation program for self-stigma (Ending Self-Stigma) and to treatment as usual (TAU). We hypothesize that diminished shame and emotional dysregulation and increased self-compassion will mediate the relationship between self-stigma improvements post-therapy in the experimental group.

METHODS

This seven-center trial will involve 336 participants diagnosed with a severe mental illness and/or autism spectrum disorder and reporting high levels of self-stigma. Participants will be randomized into one of three treatment arms: 12 week-treatment of compassion-focused therapy (experimental arm), 12 week-treatment of Psychoeducation (active control arm), and TAU (treatment as usual-passive control arm). The primary outcome is the decrease of self-stigma scores on a self-report scale, i.e., ISMI, at 12 weeks. Secondary endpoints include sustainability of self-stigma scores (ISMI) and self-reported scores regarding target psychological dimensions, e.g., shame and emotional regulation, social functioning, and psychiatric symptoms. Assessments are scheduled at pretreatment, post-treatment (at 12 weeks), and at 6-month follow-up. Acceptability will be evaluated via (i) the Credibility and Expectancy Questionnaire at T0, (ii) the Consumer Satisfaction Questionnaire for Psychotherapeutic Services posttreatment and at 6-month follow-up, (iii) attendance, and (iv) dropout rates.

DISCUSSION

This study will evaluate the potential efficacy and acceptability of a group-based CFT program on the decrease of self-stigma and thereby contribute to the continuing development of evidence-based therapeutic interventions for the internalized stigma of mental and neurodevelopmental disorders.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05698589. Registered on January 26, 2023.

Narrative enhancement and cognitive therapy for perceived stigma of chronic schizophrenia: A multicenter randomized controlled trial study

This study explored the effects of NECT on self-stigma among people with schizophrenia. Eighty-six participants were recruited and assigned to two groups. The NECT group received 20-session group meetings, while the control group received routine care. Self-stigma was measured by Internalized Stigma of Mental Illness Scale (ISMIS) and Discrimination and Stigma Scale (DISC). Generalized estimating equations were employed to explore the intervention's effectiveness. The NECT group showed a significant reduction in ISMIS total scores after 20 sessions and Stopping Self subscale scores of DISC decreased over time. The intervention is effective for improving self-stigma in people with schizophrenia.

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.

Auditory Hallucinations, Depressive Symptoms, and Current Suicidal Ideation or Behavior Among Patients with Acute-episode Schizophrenia

Suicide risk and auditory hallucinations are common in schizophrenia, but less is known about its associations. This cross-sectional study aimed to determine whether the presence and severity of auditory hallucinations were associated with current suicidal ideation or behavior (CSIB) among patients with schizophrenia. We interviewed 299 individuals with schizophrenia and acute symptoms and reviewed their medical records. Measurement included the Psychotic Symptom Rating Scale (PSYRATS-AH), the Calgary Depression Scale for Schizophrenia (CDSS), and the Positive and Negative Syndrome Scale. Logistic regression and path analysis were used. The CSIB prevalence was higher among patients with current auditory hallucination than those without (19.5% vs. 8.6%, crude odds ratio = 2.58, p = .009). Lifetime auditory hallucination experience (adjusted odds ratio [AOR] = 3.81; 95% CI: 1.45-10.05) or current auditory hallucination experience (AOR = 3.22; 95% CI: 1.25-8.28) can elevate the likelihood of CSIB while controlling for depressive symptoms and lifetime suicide-attempt history. Among those with auditory hallucinations, the emotional score of the PSYRATS-AH was positively associated with the CDSS score and there was a small indirect effect of the CDSS score on the association between the emotional domain score and CSIB (bias-corrected 95% CI, 0.02-0.20). In conclusion, the presence of auditory hallucinations was strongly associated with CSIB, independent of depressive symptoms and lifetime suicide attempts. Suicide risk assessment should consider auditory hallucination experience and patients' appraisal of its emotional characteristics. Future cohort studies are necessary to provide more conclusive evidence for the mediating pathways between auditory hallucinations and CSIB.HIGHLIGHTSThe presence of auditory hallucinations was associated with current suicidality.Auditory hallucinations' emotional severity was related to depressive symptoms.The severity of auditory hallucination was not directly associated with suicidality.

Emotion regulation relates to clinical characteristics and quality of life but not daily functioning in psychosis spectrum outpatients

Difficulties in emotion regulation (ER) can negatively impact the clinical course and outcomes of a range of psychiatric conditions, including psychosis spectrum disorders. Individuals with psychosis may exhibit poorer ER abilities, which have been associated with increased severity and distress of psychotic symptoms. A paucity of research has investigated the clinical correlates of ER in psychosis and the influence of these difficulties on indices of recovery, such as daily functioning and quality of life. In the present study, 59 outpatients presenting for Cognitive Behaviour Therapy for psychosis (CBTp) in a large psychiatric hospital completed an intake assessment of clinician-rated and self-reported measures prior to treatment. Poor ER abilities were positively correlated with positive symptoms (overall and delusions), social anxiety, depression, and self-reflectiveness and negatively correlated with quality of life and personal recovery. Multiple regression analyses showed ER was a significant predictor of quality of life but not daily functioning, which was predicted most by cognition and psychiatric symptoms. Overall, findings support the clinical utility of assessing emotion dysregulation in psychosis and provide a more nuanced understanding of how such challenges differentially influence recovery in psychosis, which can further inform treatment planning and intervention.

Even mild internalized stigma merits attention among adults with serious mental illness

Internalized or self-stigma can be damaging to psychological and social functioning and recovery, especially for people with serious mental illness. Most studies have focused on the effects of high self-stigma, which has included both moderate and high self-stigma, versus low levels of self-stigma which has included no, minimal, or mild self-stigma. Therefore, little is known about the variation within these categories (e.g., minimal versus mild self-stigma) and its impact on recovery. This article examines differences in the demographic, clinical, and psychosocial variables associated with different levels of self-stigma severity. Baseline data (N = 515) from two concurrent randomized controlled trials of a psychosocial intervention aimed at reducing internalized stigma, and its effects among adults with serious mental illnesses were examined. We found that participants with greater psychological sense of belonging, and greater perceived recovery were significantly less likely to have mild or moderate/high internalized stigma than minimal stigma. Those reporting a greater frequency of stigma experiences, however, were more likely to have mild or moderate/high internalized stigma than minimal stigma. Our findings further underscore the multifaceted nature and impact of self-stigma, particularly in interpersonal relationships and interactions, and demonstrate the importance of attending to even mild levels of self-stigma endorsement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

[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.

Clinical insight in first episode psychosis: the role of metacognition

BACKGROUND

Poor clinical insight has been commonly reported in those with First Episode Psychosis (FEP) and thought to be influenced by a range of factors, including neurocognition and symptoms. Clinical insight may be compromised as a result of alterations in higher-level reflective processes, such as metacognitive ability and cognitive insight.

AIMS

To explore whether metacognitive ability and cognitive insight are associated with clinical insight while controlling for IQ, depression, and symptoms in FEP.

METHODS

60 individuals with FEP completed measures for clinical insight, metacognitive ability, cognitive insight, positive and negative symptoms, depression, and IQ.

RESULTS

Higher levels of metacognitive ability were associated with better clinical insight, even when controlling for IQ, depression, positive and negative symptoms, and medication. Integration subscale of metacognitive ability was most strongly associated with clinical insight. Cognitive insight was associated with clinical insight when controlling for covariates. However, when including metacognitive ability and cognitive insight in the predictive model, only metacognitive ability was significantly related to clinical insight.

DISCUSSION

Metacognitive ability, specifically the ability to describe one's evolving mental state to provide a coherent narrative, was significantly related to clinical insight, independent of covariates, and may be a potentially important target for intervention in FEP.

A pilot 1-year follow-up randomised controlled trial comparing metacognitive training to psychoeducation in schizophrenia: effects on insight

Poor insight in schizophrenia spectrum disorders (SSD) is linked with negative outcomes. This single-centre, assessor-blind, parallel-group 1-year follow-up randomised controlled trial (RCT) tested whether metacognitive training (MCT) (compared to psychoeducation) may improve insight and outcomes in outpatients with SSD assessed: at baseline (T0); after treatment (T1) and at 1-year follow-up (T2). Insight (primary outcome) was measured with (i) the Schedule for Assessment of Insight-Expanded version- (SAI-E), including illness recognition (IR), symptom relabelling (SR), treatment compliance (TC) and total insight scores (TIS); and (ii) the Beck Cognitive Insight Scale (BCIS). Between-group comparisons were nonsignificant, while within the MCT group (but not within controls) there was a significant medium effect size for improved TIS at T2 (d = 0.67, P = 0.02). Secondary outcomes included cognitive measures: Jumping to Conclusions (JTC), Theory of Mind (ToM), plus symptom severity and functioning. Compared to psychoeducation, MCT improved the PANSS excitement (d = 1.21, P = 0.01) and depressed (d = 0.76, P = 0.05) factors at T2; and a JTC task both at T1 (P = 0.016) and at T2 (P = 0.031). Participants in this RCT receiving MCT showed improved insight at 1-year follow-up, which was associated with better mood and reduced JTC cognitive bias. In this pilot study, no significant benefits on insight of MCT over psychoeducation were detected, which may have been due to insufficient power.

Functional impairment, internalized stigma, and well-being: Considerations for recovery-oriented suicide prevention for U.S. Veterans with serious mental illness

Veterans Health Administration's (VHA) Psychosocial Rehabilitation and Recovery Centers (PRRCs) provide recovery-oriented care to Veterans with serious mental illness (SMI). As part of program evaluation, PRRC providers regularly assess recovery-oriented outcomes. Given the high rates of suicidal thoughts and behaviors among Veterans with SMI, understanding such outcomes in relation to suicide risk is crucial. Among Veterans entering a PRRC (N=4,731), the present study aimed to a) report suicidal ideation frequency in the past two weeks across demographics and psychiatric diagnoses, b) explore rates of current functional impairment, internalized stigma, and well-being, and c) examine differences in suicidal ideation frequency and functional impairment, internalized stigma, and well-being. Measurements before treatment were utilized. Younger (ρ=-.08, p<.001), married (z=-5.23, p<.001) Veterans, those not identifying as Black or African American (z=-4.80, p<.001), not diagnosed with schizophrenia (z=-6.97, <.001), diagnosed with depressive disorders (z=-8.79, <.001), anxiety disorders (z=-5.01, <.001), posttraumatic stress disorder (z=-7.69, <.001), or personality disorders (z=-7.12, <.001) were significantly more likely to endorse suicidal ideation. Veterans in this cohort had higher than average functional impairment (M=18.05, SD=9.85), mild internalized stigma (M=2.36, SD=0.51), and lower than average well-being (M=18.96, SD=3.93). The more often a Veteran reported thinking about suicide in the past two weeks, the more likely the Veteran viewed themselves to be more functionally impaired (p<.001), reported higher levels of internalized stigma (p<.001), and reported lower levels of well-being (p<.001). Findings and limitations, particularly the suicidal ideation frequency measurement, are discussed to contextualize suggestions to integrate recovery-oriented practices and suicide prevention care.

Self-stigma and cognitive insight in individuals at ultra-high risk for psychosis

Background

Impaired cognitive insight and increased self-stigma have been consistently reported in individuals diagnosed with schizophrenia spectrum disorders, but little is known about its presence in individuals at ultra-high risk of developing a psychosis, although self-stigma is associated with transition.to psychosis. The current study examined whether self-stigma is already present in individuals at ultra-high risk of psychosis, and whether this is associated with impaired cognitive insight.

Methods

184 participants were recruited divided over three groups, namely individuals diagnosed with a schizophrenia spectrum disorder (SSD; n = 92, 34% females), individuals at ultra-high risk for psychosis (UHR; n = 43, 59% females) and general population controls (GPC; n = 49, 27% females). All participants completed assessments on demographic information (gender, age, education), and cognitive insight. In addition, participants with SSD and individuals at UHR completed a questionnaire on self-stigma.

Results

The level of self-stigma did not differ between individuals at UHR and individuals diagnosed with SSD. Cognitive insight also did not differ significantly between the three groups, but the subscale self-reflection differed between the three groups [F(2,184) = 4.20, p = 0.02], with the UHR and SSD groups showing more self-reflection. Pearson's correlation analyses showed that in individuals at UHR total cognitive insight and its self-reflection subscale were significantly associated with the alienation subscale of self-stigma, and in individuals with SSD self-certainty subscale of cognitive insight was significantly associated with stereotype endorsement.

Conclusion

Findings show that self-stigma was already present in the UHR phase, to a similar degree as in individuals with a diagnosis of a SSD, and is thus not dependent of previous experience of having a label of SSD. Cognitive insight in individuals at UHR of psychosis appears to be intact, but individuals at UHR showed more self-reflectiveness, and individuals at risk with high cognitive insight also experience high levels of self-stigma. Overall findings from our study suggest that pre-emptive interventions targeting self-stigma, while considering cognitive insight, are needed early on in manifestation of psychotic illness, preferably already in the UHR phase.

Depression Mediates the Relationships between Hallucinations, Delusions, and Social Isolation in First-Episode Psychosis

Social isolation is common among individuals with schizophrenia spectrum and other psychotic disorders. Research indicates that social isolation relates to poorer mental health outcomes, depression, and negative symptoms, with less known about its relationship with positive symptoms. This study examined depression as a mediator in the relationships between positive symptoms (i.e., hallucinations and delusions) and social isolation among an early treatment phase sample in the United States. Data were obtained from the Recovery After an Initial Schizophrenia Episode project of the National Institute of Mental Health's Early Treatment Program. Participants (N = 404) included adults between ages 15 and 40 in a first episode of psychosis. Data were analyzed using structural equation modeling in Mplus (Version 8). The study showed that delusions (b = .095, SE = 0.04, p < .05) and hallucinations (b = .076, SE = 0.03, p < .01) were directly related to depression, and that both delusions (b = .129, SE = 0.06, p < .05) and depression (b = .254, SE = 0.09, p < .05) were directly related to social isolation. Findings of this study determined that depression functioned as a mediator in the relationships between positive symptoms and social isolation. Targeting psychosis symptomatology and depression in treatment, improving social skills and social support networks, and considering the role of stigma in social isolation are of great importance in the prevention of poorer mental health outcomes.

A Randomized Controlled Trial of the Effects of Early Intervention Services On Insight in First Episode Psychosis

BACKGROUND AND HYPOTHESIS

Impaired insight into one's illness is common in first episode psychosis (FEP), is associated with worse symptoms and functioning, and predicts a worse course of illness. Despite its importance, little research has examined the effects of early intervention services (EIS) on insight.

DESIGNS

This paper evaluated the impact of EIS (NAVIGATE) on insight compared to usual community care (CC) in a large cluster randomized controlled trial. Assessments were conducted at baseline and every 6 months for 2 years.

RESULTS

A multilevel regression model including all time points showed a significant time by treatment group interaction (P < .001), reflecting greater improvement in insight for NAVIGATE than CC participants. Impaired insight was related to less severe depression but worse other symptoms and functioning at baseline for the total sample. At 6 months, the same pattern was found within each group except insight was no longer associated with depression among NAVIGATE participants. Impaired insight was more strongly associated with worse interpersonal relationships at 6 months in NAVIGATE than in CC, and changes in insight from baseline to 6 months were more strongly correlated with changes in relationships in NAVIGATE than CC.

CONCLUSIONS

The NAVIGATE program improved insight significantly more than CC. Although greater awareness of illness has frequently been found to be associated with higher depression in schizophrenia, these findings suggest EIS programs can improve insight without worsening depression in FEP. The increased association between insight and social relationships in NAVIGATE suggests these 2 outcomes may synergistically interact to improve each other in treatment.

Affective symptom dimensions in early-onset psychosis over time: a principal component factor analysis of the Young Mania Rating Scale and the Hamilton Depression Rating Scale

Early-onset psychosis (EOP) is a complex disorder characterized by a wide range of symptoms, including affective symptoms. Our aim was to (1) examine the dimensional structure of affective symptoms in EOP, (2) evaluate the predominance of the clinical dimensions and (3) assess the progression of the clinical dimensions over a 2-year period. STROBE-compliant prospective principal component factor analysis of Young Mania Rating Scale (YMRS) and Hamilton Depression Rating Scale-21 (HDRS-21) at baseline, 6-months, 1-year and 2-year follow-up. We included 108 EOP individuals (mean age = 15.5 ± 1.8 years, 68.5% male). The factor analysis produced a four-factor model including the following dimensions: mania, depression/anxiety, sleep and psychosis. It explained 47.4% of the total variance at baseline, 60.6% of the total variance at 6-months follow-up, 54.5% of the total variance at 1-year follow-up and 49.5% of the total variance at 2-year follow-up. According to the variance explained, the mania factor was predominant at baseline (17.4%), 6-month follow-up (23.5%) and 2-year follow-up (26.1%), while the depression/anxiety factor was predominant at 1-year follow-up (23.1%). The mania factor was the most stable; 58.3% items that appeared in this factor (with a load > 0.4) at any time point appeared in the same factor at ≥ 3/4 time points. Affective symptoms are frequent and persistent in EOP. Mania seems to be the most predominant and stable affective dimension. However, depression and anxiety may gain predominance with time. A comprehensive evaluation of the dimensional structure and the progression of affective symptoms may offer clinical and therapeutic advantages.

Psychometric properties of the Internalized Stigma of Mental Illness (ISMI-10) scale in a Dutch sample of employees with mental illness

BACKGROUND

Internalized stigma can have numerous negative effects on the well-being and employment of people with mental illness. Brief, valid, and reliable measures are needed to get a better understanding of self-stigmatization. The aim of this study is to translate the brief version of the Internalized Stigma of Mental Illness (ISMI-10) scale into a Dutch version and to assess the reliability and validity of this Dutch version in a sample of employees with mental illness.

METHODS

The ISMI-10 was translated into Dutch using the forward-backward translation procedure. The sample consisted of 161 employees with mental illness. Internal consistency was evaluated and the retest reliability was tested with 68 respondents. The construct validity was evaluated by testing convergent and divergent validity.

RESULTS

The Dutch ISMI-10 showed good internal consistency (α = 0.83) and good test-retest reliability (r = 0.73). The Dutch ISMI-10 demonstrated excellent convergent validity; high correlations were found between the Dutch ISMI-10 and hope (r = -0.54), anxiety and depression (r = 0.59), self-esteem (r = -0.56), and empowerment (r = - 0.59). Acceptable divergent validity was indicated; small correlations were found between the Dutch ISMI-10 and the physical functioning subscale (r = -0.27) and the role limitation due to physical problems subscale (r = -0.21), and medium correlations were found between the Dutch ISMI-10 and the general health subscale (r = -0.36).

CONCLUSION

The Dutch ISMI-10 demonstrated adequate psychometric properties for assessing internalized stigma and can be used by researchers in Dutch speaking countries to get a better understanding of self-stigmatization among people with mental illness.

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.

The clinical and psychosocial correlates of self-stigma among people with schizophrenia spectrum disorders across cultures: A systematic review and meta-analysis

BACKGROUND

Individuals with schizophrenia spectrum disorders (SSD) are at heightened risk of experiencing self-stigma, and some cultures are more stigmatizing towards SSD than others. The first purpose of this review is to provide an estimate of the relationship between self-stigma and clinical and psychosocial outcomes. The second purpose is to examine how these relationships vary across cultures.

METHOD

Studies reporting correlations between self-stigma and outcome variable(s) were identified through electronic database searches from June 1, 2021, to January 2, 2022. Mean effect sizes were calculated using Fisher's r-to-Z-transformation.

RESULTS

Sixty-three articles (N = 8925, 22 countries) were included in the systematic review and fifty-three articles (N = 7756) were included in the meta-analysis. For the most studied clinical correlates, self-stigma had a moderate, positive correlation with depressive symptoms (r = 0.49, p &lt; .001), a moderate, negative correlation with functioning (r = -0.39, p &lt; .001), and a positive, small correlation with severity of psychotic symptoms (r = 0.29, p &lt; .001), negative symptoms (r = 0.18, p &lt; .001) and positive symptoms (r = 0.13, p = .01). For the most studied psychosocial correlates, self-stigma had a strong, negative correlation with quality of life (r = -0.52, p &lt; .001) and self-esteem (r = -0.55, p &lt; .001). The correlates of self-stigma were similar across cultures.

DISCUSSION

Self-stigma shows strong to small correlations with clinical and psychosocial variables similarly across cultures. More research is needed to examine underlying mechanisms to develop effective interventions.

Impaired insight in schizophrenia: impact on patient-reported and physician-reported outcome measures in a randomized controlled trial

BACKGROUND

Impaired insight poses a challenge in the treatment of patients with schizophrenia because of its potential to jeopardize therapeutic engagement and medication adherence. This study explored how insight impairment, graded from none to extreme, is related to patient-reported mental health status, depression, and neurocognition in schizophrenia.

METHODS

In a post hoc analysis of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study (NCT00014001), insight was measured using the Positive and Negative Syndrome Scale (PANSS) Item G12 (lack of insight). Additional assessments for this analysis included the 12-Item Short-Form Health Survey (SF-12) Mental Component Summary (MCS), physician- and patient-reported Clinical Global Impression-Severity (CGI-S), MATRICS Consensus Cognitive Battery, and Calgary Depression Scale for Schizophrenia. Relationships between patient-reported outcomes and PANSS total and Item G12 ratings were evaluated.

RESULTS

Among 1431 CATIE study participants in this analysis, increasingly impaired insight at baseline was significantly associated with better patient-reported quality of life (QoL), lower baseline depression, and greater divergence between physician- and patient-reported illness severity. Patients with more severely impaired insight reported milder illness compared with physician reports, particularly those with moderate-severe to extreme impairment (PANSS Item G12 rating ≥ 5), approximately 10% (138/1431) of CATIE participants. For the 90% of patients with PANSS Item G12 ratings < 5, patient-reported QoL decreased with increasing symptoms. SF-12 MCS scores were linearly related to baseline PANSS total score only in patients with PANSS total score < 90 (moderately ill or better), and better symptom scores were associated with higher QoL. No significant relationship between insight and neurocognition was observed.

CONCLUSIONS

In the small subgroup (10%) of CATIE study patients with schizophrenia and PANSS Item G12 ratings ≥5, moderate-severe-severe/extreme insight impairment was associated with significantly more positive perception of QoL and illness severity by the patient versus the treating physician. This was not observed in the remaining 90% of patients with normal to moderately impaired insight, suggesting that poor insight as a threat to the validity of self-report is uncommon.

Stigma resistance is associated with advanced stages of personal recovery in serious mental illness patients enrolled in psychiatric rehabilitation

BACKGROUND

Stigma resistance (SR) is defined as one's ability to deflect or challenge stigmatizing beliefs. SR is positively associated with patient's outcomes in serious mental illness (SMI). SR appears as a promising target for psychiatric rehabilitation as it might facilitate personal recovery.

OBJECTIVES

The objectives of the present study are: (i) to assess the frequency of SR in a multicentric non-selected psychiatric rehabilitation SMI sample; (ii) to investigate the correlates of high SR.

METHODS

A total of 693 outpatients with SMI were recruited from the French National Centers of Reference for Psychiatric Rehabilitation cohort (REHABase). Evaluation included standardized scales for clinical severity, quality of life, satisfaction with life, wellbeing, and personal recovery and a large cognitive battery. SR was measured using internalized stigma of mental illness - SR subscale.

RESULTS

Elevated SR was associated with a preserved executive functioning, a lower insight into illness and all recovery-related outcomes in the univariate analyses. In the multivariate analysis adjusted by age, gender and self-stigma, elevated SR was best predicted by the later stages of personal recovery [rebuilding; p = 0.004, OR = 2.89 (1.36-4.88); growth; p = 0.005, OR = 2.79 (1.30-4.43)). No moderating effects of age and education were found.

CONCLUSION

The present study has indicated the importance of addressing SR in patients enrolled in psychiatric rehabilitation. Recovery-oriented psychoeducation, metacognitive therapies and family interventions might improve SR and protect against insight-related depression. The effectiveness of psychiatric rehabilitation on SR and the potential mediating effects of changes in SR on treatment outcomes should be further investigated in longitudinal studies.

Magnitude and factors associated with treatment non-adherence among patients with depressive disorders at St. Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia, 2019: A cross sectional study

Background

Inadequate adherence to treatment is among the main underlying causes of depression becoming a chronic problem. In developing countries due to limited access to health care, inaccurate diagnoses, and scarcity of medications, poor adherence may become an even larger obstacle in the treatment of depression. The current study aims to assess the magnitude and factors related to treatment non-adherence among patients with depressive disorders.

Objective

To assess the magnitude and factors associated with treatment non adherence among patients with depressive disorders at St. Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia, 2019.

Methods

A hospital-based cross-sectional study was conducted among 415 respondents using systematic random sampling technique. Medication adherence was assessed by using Medication Adherence Rating Scale. Data was entered to Epi-data version 3.1 and analyzed using SPSS version 20. Binary logistic analysis was done and P-values less than 0.05 were considered statistically significant.

Results

The prevalence of treatment non-adherence among patients with depressive disorders was 26% (95%CI; 21.2, 32.5). Previous suicide attempt (AOR = 3.05, 95%CI; 1.82, 5.12), medication side effects (AOR = 2.46, 95%CI; 1.47, 4.11), moderate to high self-stigma (AOR = 2.60, 95%CI; 1.45, 4.66), and poor quality of life (AOR = 2.47, 95%CI; 1.42, 4.28) were significantly associated with treatment non-adherence among patients with depressive disorders.

Conclusion and recommendation

Treatment non-adherence is a common problem among patients being treated for depressive disorders. Previous suicide attempts, medication side effects, moderate to high self-stigma, and poor quality of life were significantly associated with treatment non-adherence. Appropriate interventions should be developed to promote measures to facilitate adherence in this group of patients, and address the associated factors when applicable.

Metacognitive mastery moderates the relationship between positive symptoms and distress in adults with serious mental illness

BACKGROUND

Research supports the possibility that a person's metacognitive ability may influence the impact of positive symptoms. This connection is important because understanding how metacognitive capacity relates to positive symptoms and distress can guide treatment and bolster recovery.

AIMS

To explore this, we assessed the moderating role of Metacognitive Mastery on the relationship of positive symptoms to affective symptoms, or markers of distress, measured both concurrently and at a later time point (to assess durability of metacognition) with persons with serious mental illness. To rule out the possibility that any findings were the result of cognitive impairments or general psychopathology we included measures of neurocognition and symptoms as potential covariates.

METHODS

Participants were 67 individuals with the majority diagnosed with either schizophrenia spectrum disorder, major depressive disorder, or bipolar disorder. Metacognition was measured with the Metacognitive Assessment Scale-Abbreviated, symptoms were measured using the Brief Psychiatric Rating Scale and verbal memory was measured using the California Verbal Learning Test.

RESULTS

Metacognitive Mastery moderated the relationship between positive symptoms and affective symptoms at both time points with differential patterns at each point.

CONCLUSIONS

Metacognitive Mastery may exert a complex influence upon the effects of positive symptoms on distress.