Psychosocial interventions for internalised stigma in people with a schizophrenia-spectrum diagnosis: A systematic narrative synthesis and meta-analysis

Interventions to Reduce Internalized Stigma in individuals with Mental Illness: A Systematic Review

Internalized stigma has a high prevalence in people with mental health problems and is associated with negative consequences in different areas: work, social, personal, etc. Therefore, it is relevant to systematically study the characteristics and effectiveness of the different psychological and psychosocial interventions aimed at reducing it. Through the databases MEDLINE and PsycINFO, among others, controlled studies on specific interventions to reduce internalized stigma in people with severe mental disorders published between 2008 and 2018 were selected and reviewed. Results showed that the interventions can be grouped into four blocks: (a) psychoeducational interventions about stigma; (b) cognitive-behavioral interventions, mainly aimed at modifying self-stigmatizing beliefs; (c) interventions focused on the revelation of mental illness; and (d) multicomponent interventions that combine several of the above. The interventions had an average of 10 sessions and were predominantly applied in group format. In 9 of the 14 studies reviewed, significant results were obtained in the reduction of internalized stigma with small or moderate effect sizes. There were also significant improvements in other variables, such as subjective recovery or coping. The main methodological limitation of the studies reviewed was the absence of information on the rejection rate. We conclude that there are effective interventions aimed at reducing internalized stigma, with psychoeducational interventions on stigma and multicomponent interventions showing the best results. Cognitive-behavioral interventions and interventions based on disclosure have been studied to a lesser extent and their results are inconclusive. Future research should focus on establishing optimal interventions according to characteristics and objectives of individuals.

The relationship between self-stigma and depression among people with schizophrenia-spectrum disorders: A longitudinal study

Harmful consequences of self-stigma in schizophrenia are well established in the literature, but its relationship with symptomatology remains unclear. Self-stigma describes the process by which some patients eventually accept, adhere to and apply to themselves the stereotypes associated with schizophrenia. This study aims to describe self-stigma experienced by people with schizophrenia in French-speaking Switzerland and to examine the relationship between self-stigma and depression. This was a longitudinal study including 80 participants. Correlation and regression analyses were used to examine the relationship between self-stigma and depression over three points of time. Correlations between Stigma Scale subdimensions and sociodemographic variables indicated that age and duration of illness were associated with the discrimination subscale. Self-stigma was strongly correlated with depression over time, whereby higher scores of self-stigma were associated with higher depression. More precisely, the more the patient felt discriminated against and the less he or she perceived the positive aspects of his or her illness, the greater the symptoms of depression. This study highlights the severity of self-stigma endorsed by people with schizophrenia in French-speaking Switzerland. The results provide new knowledge about self-stigma and its potential impact on depressive symptoms. Implementation of self-stigma assessment in clinical practice will allow distinctions to be made between the impact of self-stigma and the consequences of schizophrenia to recommend appropriate intervention.

Disclosing the diagnosis of schizophrenia: A pilot study of the 'Coming Out Proud' intervention

BACKGROUND

Schizophrenia is one of the most stigmatized psychiatric disorders, and disclosing it is often a source of stress to individuals with the disorder. The Coming Out Proud (COP) group intervention is designed to reduce the stigma's negative impact and help participants decide if they want to disclose their disorder.

AIMS

To assess the effect of the COP intervention in individuals with the diagnosis of schizophrenia.

METHODS

A pilot study of 3 2-hour group lessons (6-12 participants) per week. Individuals were selected from three specialized outpatient services in São Paulo, Brazil; 46 people were willing to participate, 11 dropped out during the intervention and 4 were excluded due to low intelligence quotient (IQ), resulting in a final sample of 31 participants. Outcomes were assessed before ( T0/baseline) and after ( T1/directly) after the COP intervention, and at 3-week follow-up ( T2/3 weeks after T1). We applied eight scales, of which four scales are analyzed in this article (Coming Out with Mental Illness Scale (COMIS), Cognitive Appraisal of Stigma as a Stressor (CogApp), Self-Stigma of Mental Illness Scale-Short Form (SSMIS) and Perceived Devaluation-Discrimination Questionnaire (PDDQ)).

RESULTS

People who completed the COP intervention showed a significant increase in the decision to disclose their diagnosis (22.5% in T0 vs 67.7% in T2). As to the perception of stigma as a stressor, mean values did not significantly differ after the intervention. Two results had marginal significance: self-stigma was reduced ( T0 = 3.10, SD = 1.70 vs T2 = 2.73, SD = 1.87; p = .063), while perceived discrimination increased ( T0 = 2.68, SD = .55 vs T2 = 2.93, SD = .75; p = .063).

CONCLUSION

This study suggests that the COP group intervention facilitated participants' disclosure decisions. The results raise questions that require further analysis, taking sociocultural factors into account, as stigma is experienced differently across cultures.

Neural and cognitive correlates of stigma and social rejection in individuals with Serious Mental Illness (SMI): A systematic review of the literature

Stigma and self-stigma are major issues for people with Serious Mental Illness (SMI). This review's aims were to determine the cognitive and neural processes underlying the effects of stigma and social rejection in people with SMI. A stepwise systematic literature review (PRISMA) was conducted by searching PubMed, Medline and Web of Science using the following keywords: "cyberball" OR "stereotype threat" OR "implicit association test" AND "mental illness". The articles included met the following criteria: (a) reporting on social rejection, stigma or self-stigma (b) diagnosis of SMI (c) available data on the underlying mechanisms. Our search on July 31th 2018 found in 955 articles on PubMed and 3,362 on Web of Science. Hypersensitivity to acute social rejection was found and associated with more self-related negative emotions and more dysfunctional emotion regulation strategies. People with SMI under-performed in cognitive tasks when confronted with stigma. Stigma resistance was described with its neural correlates. Psychiatric symptoms, duration of illness and baseline non-specific distress influenced the response to acute social rejection or stigma. The samples, methods, and reported outcomes were heterogeneous and difficult to compare. Future studies should investigate the associations between self-stigma and responses to acute and chronic social rejection.

'Management of a spoiled identity': systematic review of interventions to address self-stigma among people living with and affected by HIV

Background

Self-stigma, also known as internalised stigma, is a global public health threat because it keeps people from accessing HIV and other health services. By hampering HIV testing, treatment and prevention, self-stigma can compromise the sustainability of health interventions and have serious epidemiological consequences. This review synthesised existing evidence of interventions aiming to reduce self-stigma experienced by people living with HIV and key populations affected by HIV in low-income and middle-income countries.

Methods

Studies were identified through bibliographic databases, grey literature sites, study registries, back referencing and contacts with researchers, and synthesised following Cochrane guidelines.

Results

Of 5880 potentially relevant titles, 20 studies were included in the review. Represented in these studies were 9536 people (65% women) from Ethiopia, India, Kenya, Lesotho, Malawi, Nepal, South Africa, Swaziland, Tanzania, Thailand, Uganda and Vietnam. Seventeen of the studies recruited people living with HIV (of which five focused specifically on pregnant women). The remaining three studies focused on young men who have sex with men, female sex workers and men who inject drugs. Studies were clustered into four categories based on the socioecological level of risk or resilience that they targeted: (1) individual level only, (2) individual and relational levels, (3) individual and structural levels and (4) structural level only. Thirteen studies targeting structural risks (with or without individual components) consistently produced significant reductions in self-stigma. The remaining seven studies that did not include a component to address structural risks produced mixed effects.

Conclusion

Structural interventions such as scale-up of antiretroviral treatment, prevention of medication stockouts, social empowerment and economic strengthening may help substantially reduce self-stigma among individuals. More research is urgently needed to understand how to reduce self-stigma among young people and key populations, as well as how to tackle intersectional self-stigma.

The Multiple Dimensions of Insight in Schizophrenia-Spectrum Disorders

The concept of insight is used to indicate the propensity of patients with schizophrenia and other severe mental disorders to recognize their illness and engage in treatment. Thus, insight may have notable consequences for the ill individual: Those who lack insight are at higher risk of nonadherence to treatments, negative clinical outcomes, and worse community functioning. Although insight is an intuitive concept, its essence remains difficult to capture. However, many rating scales are available to aid assessment, both for clinical and research purposes. Insight cannot be reduced to a symptom, a psychological mechanism, or a neuropsychological function. It is likely to have dynamic relationships with all these dimensions and with responses to personal events and contextual factors. In particular, social consequences of mental illness and explanatory models that are alternative to the medical model may fundamentally shape insight and treatment choice. Moreover, the cultural or individual stigmatization of mental illness may turn the acquisition of insight into a painful event and increase the risk of depression. Clinicians need to carefully evaluate and promote insight through a personalized approach to aid patient process of care and personal growth.

A new brief opioid stigma scale to assess perceived public attitudes and internalized stigma: Evidence for construct validity

One key strategy to improve treatment access for persons with opioid use disorder (OUD) is overcoming stigma that is internalized by such individuals. Because few theoretically-derived, multidimensional measures of substance abuse stigma exist, we contribute a brief, theoretically-based measure of opioid-related stigma (adapted from Corrigan's Self-Stigma of Mental Illness Scale) to assess perceived stigma and internalized stigma among individuals with OUD. This study presents initial validation of the newly-developed Brief Opioid Stigma Scale among 387 adults who entered an inpatient opioid managed-withdrawal program. The scale assesses: (1) Stereotype awareness ("Aware"), or the extent to which individuals who use opioids perceive community members to believe OUD-related stereotypes; (2) Stereotype agreement ("Agree"), or the endorsement of stigmatizing beliefs by individuals who use opioids; (3) Self-esteem decrement ("Harm"), or the diminution of self-esteem due to these negative stereotypes' impacts on self-worth. Psychosocial measures including self-esteem, depressive symptoms, mental and physical functioning, and desire for aftercare OUD medication treatment, were administered to assess construct validity. Results showed that greater endorsement of the "harm" stigma subscale was associated with greater depressive symptoms, lower self-esteem, and poorer mental and physical functioning. The "aware" stigma subscale displayed similar overall patterns of associations with self-esteem and depression but to a lesser magnitude. The "aware" stigma subscale was positively associated with desire for aftercare methadone and naltrexone treatment, and the "harm" subscale was positively associated with desire for aftercare buprenorphine treatment. Results indicated good initial construct validity. Tailored stigma interventions are recommended for specific aftercare OUD medication treatments.

The Effect of Counseling on Stigma in Psychiatric Patients Receiving Electroconvulsive Therapy: A Clinical Trial Study

PURPOSE

Despite its efficacy and safety, electroconvulsive therapy (ECT) is underutilized, in part, due to the stigma associated with the treatment. This study aimed to evaluate the effect of counseling on stigma in patients with psychiatric disorders receiving ECT.

PATIENTS AND METHODS

A total of 114 patients with psychiatric disorders undergoing ECT were randomly divided into two groups. Both the groups received routine care and treatment, but the intervention group (n=57) received four counseling sessions. At the beginning and end of the study (6 weeks, post-treatment), patients completed the Internalized Stigma of Mental Illness scale. The data were analyzed using independent and paired sample t-tests.

RESULTS

There was no significant difference in the mean stigma scores of participants in the control and intervention groups before counseling (P>0.08). However, post-intervention, there was a significant difference in the mean stigma scores between both the groups (P<0.001).

CONCLUSION

The findings demonstrate that the counseling intervention is effective in decreasing stigma in patients undergoing ECT. Therefore, it is recommended to use this therapeutic method in such patients.

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

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

Internalised stigma in mental health: An investigation of the role of attachment style

Internalised stigma is associated with a range of negative outcomes, yet little is known about what determines the internalisation of stigma. In this study we examined the potential role of adult attachment style in the internalisation process in a transdiagnostic sample of adults with experience of recent mental health service use (n = 122), using an online survey. Associations between internalised stigma and perceived public stigma were tested. We also examined whether anxious and avoidant (insecure) attachment styles were positively associated with a significant amount of variance in internalised stigma when controlling for other variables, and whether the relationship between perceived public stigma and internalised stigma was moderated by anxious and avoidant attachment. We found that internalised stigma, perceived public stigma and insecure attachment were commonly reported and that internalised stigma was positively associated with perceived public stigma. However, neither anxious or avoidant attachment were associated with a significant amount of variance in internalised stigma and we found no moderating effect on the relationship between perceived public stigma and internalised stigma for insecure attachment. Despite mixed results, the strength of association between anxious attachment and internalised stigma suggests further research, which addresses some limitations of the current study, is warranted.

Interventions to reduce stigma towards people with severe mental illness: Systematic review and meta-analysis

This review evaluates the evidence on what interventions are effective in reducing public stigma towards people with severe mental illness, defined as schizophrenia, psychosis or bipolar disorder. We included 62 randomised controlled trials of contact interventions, educational interventions, mixed contact and education, family psychoeducation programs, and hallucination simulations. Contact interventions led to small-to-medium reductions in stigmatising attitudes (d = 0.39, 95% CI: 0.22 to 0.55) and desire for social distance (d = 0.59, 95% CI: 0.37 to 0.80) post-intervention, but these were reduced after adjusting for publication bias (d = 0.24 and d = 0.40, respectively). Effects did not vary by type or length of contact. Effects at follow-up were smaller and not significant. Education interventions led to small-to-medium reductions in stigmatising attitudes (d = 0.30, 95% CI: 0.14 to 0.47) and desire for social distance (d = 0.27, 95% CI: 0.08 to 0.46) post-intervention. Small improvements in social distance persisted up to 6 months later (d = 0.27, 95% CI: 0.05 to 0.49), but not attitudes (d = 0.03, 95% CI: -0.12 to 0.18). The combination of contact and education showed similar effects to those that presented either intervention alone, and head-to-head comparisons did not show a clear advantage for either kind of intervention. Family psychoeducation programs showed reductions in stigma post-intervention (d = 0.41, 95% CI: 0.11 to 0.70). The effectiveness of hallucination simulations was mixed. In conclusion, contact interventions and educational interventions have small-to-medium immediate effects upon stigma, but further research is required to investigate how to sustain benefits in the longer-term, and to understand the active ingredients of interventions to maximise their effectiveness.

Stigma and intersectionality: a systematic review of systematic reviews across HIV/AIDS, mental illness, and physical disability

Background

Stigma across HIV/AIDS, mental illness, and physical disability can be co-occurring and may interact with other forms of stigma related to social identities like race, gender, and sexuality. Stigma is especially problematic for people living with these conditions because it can create barriers to accessing necessary social and structural supports, which can intensify their experiences with stigma. This review aims to contribute to the knowledge on stigma by advancing a cross-analysis of HIV/AIDS, mental illness, and physical disability stigma, and exploring whether and how intersectionality frameworks have been used in the systematic reviews of stigma.

Methods

A search of the literature was conducted to identify systematic reviews which investigated stigma for HIV/AIDS, mental illness and/or physical disability. The electronic databases MEDLINE, CINAHL, EMBASE, COCHRANE, and PsycINFO were searched for reviews published between 2005 and 2017. Data were extracted from eligible reviews on: type of systematic review and number of primary studies included in the review, study design study population(s), type(s) of stigma addressed, and destigmatizing interventions used. A keyword search was also done using the terms “intersectionality”, “intersectional”, and “intersection”; related definitions and descriptions were extracted. Matrices were used to compare the characteristics of reviews and their application of intersectional approaches across the three health conditions.

Results

Ninety-eight reviews met the inclusion criteria. The majority (99%) of reviews examined only one of the health conditions. Just three reviews focused on physical disability. Most reviews (94%) reported a predominance of behavioural rather than structural interventions targeting stigma in the primary studies. Only 17% of reviews used the concept and/or approach of intersectionality; all but one of these reviews examined HIV/AIDS.

Conclusions

The lack of systematic reviews comparing stigma across mental illness, HIV/AIDS, and physical disability indicates the need for more cross-comparative analyses among these conditions. The integration of intersectional approaches would deepen interrogations of co-occurring social identities and stigma.

A brief cognitive therapy intervention for internalised stigma in acute inpatients who experience psychosis: A feasibility randomised controlled trial

Internalised stigma is problematic for people who experience psychosis therefore psychological interventions are required. This study examine the feasibility and acceptability of a brief Cognitive Behavioural Therapy (CBT) intervention for internalised stigma with psychiatric inpatients experiencing psychosis. A feasibility randomised controlled trial was conducted, comparing CBT with a psychoeducational (PE) control arm. Thirty participants (aged 18-65, with psychosis, and currently admitted to a psychiatric hospital) were randomised to one of two conditions. Participants were assessed at baseline, post-intervention (two weeks) and at follow-up (one month). Both interventions incorporated two hours of sessions over a two week period. The outcomes examined were internalised stigma (primary outcome), stigma, attitudes toward mental health problems, personal recovery, depression and self-esteem. Recruitment was conducted over a seven month period from five psychiatric wards. Forty five potential participants were approached and 30 (66%) consented to take part. Fifteen participants were randomised to CBT and 15 to PE. Feasibility data demonstrated that both the research process and interventions were feasible and acceptable. Examination of outcomes demonstrated that there was no identified benefit of one intervention type over another. There were no adverse events related to study participation. A future definitive trial is required with improved methodological rigor.

The relationship between internalized stigma and quality of life among people with mental illness: are self-esteem and sense of coherence sequential mediators?

PURPOSE

To elucidate the mechanism through which internalized stigma reduces the quality of life (QoL) of people with mental illness by exploring the mediating roles of self-esteem and sense of coherence (SOC).

METHODS

A cross-sectional analysis of 229 patients diagnosed with schizophrenia or affective disorders was undertaken to test a sequential mediation model assuming that more severe internalized stigma is related to lower self-esteem, which is associated with weaker SOC, which in turn relates to worse QoL.

RESULTS

The proposed model was supported by the data. A sequential indirect effect from internalized stigma to QoL via self-esteem and SOC turned out to be significant [beta = -0.06, SE = 0.02; 95% CI (-0.11, -0.03)]. Support was also found for simple mediation models with either self-esteem or SOC as single mediators between internalized stigma and QoL.

CONCLUSIONS

Self-esteem and SOC are personal resources that should be considered as potential targets of interventions aiming to prevent the harmful consequences of internalized stigma for the QoL of people receiving psychiatric treatment.

An Integrative Cognitive Model of Internalized Stigma in Psychosis

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

How Do People Experiencing Schizophrenia Spectrum Disorders or Other Psychotic Disorders Use the Internet to Get Information on Their Mental Health? Literature Review and Recommendations

BACKGROUND

Studies show that the Internet has become an influential source of information for people experiencing serious psychiatric conditions such as schizophrenia spectrum disorders or other psychotic disorders, among which the rate of Internet users is growing, with rates ranging from 33.3% to 79.5% given the country. Between 20.5% and 56.4% of these Internet users seek mental health information.

OBJECTIVE

Focusing on this population's Web searches about their mental health, this paper examines what type of content they look for and what could be the benefits and disadvantages of this navigation.

METHODS

We conducted a literature review through medical and psychological databases between 2000 and 2015 using the keywords "Internet," "Web," "virtual," "health information," "schizophrenia," "psychosis," "e-mental health," "e-support," and "telepsychiatry."

RESULTS

People experiencing schizophrenia spectrum disorders or other psychotic disorders wish to find on the Internet trustful, nonstigmatizing information about their disease, flexibility, security standards, and positive peer-to-peer exchanges. E-mental health also appears to be desired by a substantial proportion of them. In this field, the current developments towards intervention and early prevention in the areas of depression and bipolar and anxiety disorders become more and more operational for schizophrenia spectrum disorders and other psychotic disorders as well. The many benefits of the Internet as a source of information and support, such as empowerment, enhancement of self-esteem, relief from peer information, better social interactions, and more available care, seem to outbalance the difficulties.

CONCLUSIONS

In this paper, after discussing the challenges related to the various aspects of the emergence of the Internet into the life of people experiencing schizophrenia spectrum disorders or other psychotic disorders, we will suggest areas of future research and practical recommendations for this major transition.

Rehabilitation Interventions to Promote Recovery from Schizophrenia: A Systematic Review

Only one out of seven patients recovers after a first episode of psychosis despite psychiatric care. Rehabilitation interventions have been developed to improve functional outcomes and to promote recovery. We conducted a systematic review of the effectiveness of the main psychiatric rehabilitation interventions following a search of the electronic databases Pubmed, ScienceDirect, and Google Scholar using combinations of terms relating to cognitive remediation, psychoeducation, cognitive-behavioral therapies, and schizophrenia. Eighty articles relevant to the topic of interest were found. According to results, cognitive remediation has been found to be effective in reducing the impact of cognitive impairment, social skills in the learning a variety of skills and to a lesser extent in reducing negative symptoms, psychoeducation in improving compliance and reducing relapses, and cognitive therapy in reducing the intensity of or distress related to positive symptoms. All psychosocial rehabilitation interventions should be considered as evidence-based practices for schizophrenia and need to become a major part of the standard treatment of the disease.