Understanding reduced activity in psychosis: the roles of stigma and illness appraisals

Societal recovery trajectories in people with a psychotic disorder in long term care: a latent class growth analysis

PURPOSE

For many individuals with a psychotic disorder societal recovery is not accomplished. Research on societal recovery trajectories is mostly focussed on patients with a first episode psychosis. The present study aims to identify distinct societal trajectories in those with long duration of illness, through the identification of patient subgroups that are characterized by homogeneous trajectories.

METHODS

Longitudinal data were used from an ongoing dynamic cohort in which people with a psychotic disorder receive yearly measurements to perform a latent class growth analysis. Societal functioning was assessed with the Functional Recovery tool, consisting of three items (1) daily living and self-care, (2) work, study and housekeeping, and (3) social contacts. Furthermore, logistic regression was used to compare subgroups with similar societal recovery at baseline, but distinct trajectories.

RESULTS

A total of 1476 people were included with a mean treatment time of 19 years (SD 10.1). Five trajectories of functioning were identified, a high stable (24.5%), a medium stable (28.3%), a low stable (12.7%), a high declining (11.2%) and a medium increasing subgroup (23.3%). Predictors for not deteriorating included happiness, recent hospitalisation, being physically active, middle or higher education and fewer negative symptoms. Predictors for improving included fewer positive and negative symptoms, fewer behavioural problems and fewer physical and cognitive impairments.

CONCLUSION

While the majority of individuals show a stable trajectory over four years, there were more patients achieving societal recovery than patients deteriorating. Predictors for improvement are mainly related to symptoms and behavioural problems, while predictors for deteriorating are related to non-symptomatic aspects such as physical activity, happiness and level of education.

Community Participation Among Individuals with Severe Mental Disorders During COVID-19 Pandemic

Utilizing a sample of 286 community-dwelling adults with severe mental disorders (SMDs) in Beijing, this study examined their social and community participation during COVID-19 pandemic. The descriptive results showed that adults with SMDs living in the pandemic Beijing mostly engaged in social activities, followed by productive and leisure/recreational activities. More than two-thirds of the participants indicated that their participation was not sufficient. The multivariate analyses revealed that higher social support and self-esteem predicted more participation days, higher social support and independent usage of Health Kit were linked to more participation items, while higher social support and stronger self-stigma were associated with lower perceived participation sufficiency. Thus, community mental health professionals need to provide more tailored interventions to people with SMDs to enhance their participation performance and perceived participation sufficiency during the pandemic era.

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 < .001), a moderate, negative correlation with functioning (r = -0.39, p < .001), and a positive, small correlation with severity of psychotic symptoms (r = 0.29, p < .001), negative symptoms (r = 0.18, p < .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 < .001) and self-esteem (r = -0.55, p < .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.

Personality Factors Crucial in Internalized Stigma Understanding in Psychiatry

Objective: The main purpose of this research was to establish the relationship between personality traits and internalized stigma in individuals living with severe mental illness. Additionally, the study aimed to identify individual differences that could be used to develop the theoretical socio-cognitive-behavioral equation model of internalized stigma. Methods: A total of 114 patients with diagnosis of nonorganic psychotic disorder or uni- or bipolar affective disorder took part in this study. The Internalized Stigma of Mental Illness (ISMI) scale, Eysenck Personality Questionnaire Revised (EPQ-R) and NEO Five-Factor Inventory (NEO-FFI) were administrated among all participants. Results: Patients presenting higher levels of neuroticism scored higher on the ISMI scale. Otherwise, those with higher levels of extraversion, openness to experience and conscientiousness had lower ISMI scores. With the use of multivariate linear regression, neuroticism, openness to experience and conscientiousness showed the strongest associations with internalized stigma. Conclusions: Intrapersonal factors such as personality traits might explain individual differences in responses to the stigmatization process. Moreover, sociodemographic conditions such as the place of residence and level of education can play a mediating role in reducing the level of internalized stigma. Adequate psychosocial interventions should consider demographics and personality traits when engaging patients with mental illnesses in activities aimed at understanding and accepting the disorders.

Assessment of illness representations in mental disorders: A mini review

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

Factors associated with internalized stigma for Indonesian individuals diagnosed with schizophrenia in a community setting

WHAT IS KNOWN ON THE SUBJECT?: Internalized stigma in people diagnosed with mental illness has several negative outcomes; however, it remains unclear in an Indonesian context. The human rights of people diagnosed with mental illness in Indonesia have been routinely violated because of the existing stigma against mental illness and deficiencies in the country's mental healthcare services. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: To the best of our knowledge, this is the first study to examine the level of internalized stigma and related factors among Indonesians diagnosed with schizophrenia. Almost one-third of the subjects had moderate-to-severe levels of internalized stigma, among which discrimination was the strongest type. Specifically, younger and unemployed people with more psychotic symptoms had higher levels of internalized stigma. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The provision of adequate pharmacological and psychosocial treatments to help people manage their psychotic symptoms is extremely important to ameliorate stigma. Vocational rehabilitation and employment support for unemployed people may potentially reduce their internalized stigma and promote recovery. ABSTRACT: Introduction The human rights of people diagnosed with mental illness in Indonesia have been routinely violated because of societal stigma associated with mental illness and deficiencies in the country's mental healthcare services. Knowledge about internalized stigma among people diagnosed with schizophrenia in lower middle-income Muslim countries is also scarce. Aim To identify the level of internalized stigma and related factors among people diagnosed with schizophrenia in Indonesia. Method A cross-sectional survey was conducted with a purposive sample of 300 people diagnosed with schizophrenia from an urban Indonesian psychiatric hospital. Results Almost one-third of the subjects had moderate-to-severe levels of internalized stigma, among which discrimination was the strongest type. Younger age, unemployment status and having psychotic symptoms significantly increased the risk of internalized stigma when analysed in a multivariable ordinal logistic regression. Discussion The present study firstly identified the high levels of internalized stigma among Indonesian individuals diagnosed with schizophrenia. Implications for practice Mental health nurses are suggested to provide early anti-stigma illness management and family psychoeducation interventions to people diagnosed with schizophrenia and their family caregivers, helping them to develop an optimistic understanding about the concept of schizophrenia and mitigating the negative consequences of public and internalized stigma.

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

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

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

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

Correlates of internalized stigma levels in people with psychosis in the Czech Republic

BACKGROUND

Internalized stigma negatively affects lives and prognosis of individuals with psychosis.

AIM

This study aimed to identify correlates of internalized stigma among individuals with psychosis in a sample of community care users in the Czech Republic.

METHODS

A cross-sectional study was conducted among 133 community service users with psychosis. A shortened version of the Internalized Stigma of Mental Illness (ISMI-10) scale was used alongside the 5-level EQ-5D version (EQ-5D-5L), assessing health-related quality of life. Descriptive and linear regression analyses were performed in order to determine levels of internalized stigma and its correlates.

RESULTS

High levels of internalized stigma were reported in 25% of participants. Lower internalized stigma levels were associated with better self-reported health status and being married, and higher internalized stigma with a longer period of time since initial contact with psychiatric care.

CONCLUSION

Lower internalized stigma levels are associated with better self-reported health-related quality of life. In addition, clients having used psychiatric care for longer periods of time reported significantly higher internalized stigma levels. Therefore, authors suggest self-stigma reduction interventions based in a community setting with an emphasis on targeting clients with chronic psychosis.

Do recovery outcome measures improve clinical practice? A linguistic analysis of the impact of the Hope, Agency and Opportunity measure in community mental health teams

AIMS

Recovery approaches are identified as the overarching framework for improving mental health services for people with severe and enduring conditions. These approaches prioritise living well with long-term conditions, as evidenced by personal recovery outcomes. There is little research demonstrating how to support busy mental health teams, work in this way. This study assessed the impact of introducing a brief measure of recovery, the Hope, Agency and Opportunity (HAO), on the attitudes and behaviours of staff working in community mental health teams, to test whether routine use of such measures facilitates recovery-based practice.

METHODS

Linguistic analysis assumes that language is indicative of wider attitudes and behaviours. Anonymised clinical notes recorded by community mental health team clinicians were analysed for recovery and non-recovery language, over 30 months. This covered periods before, during and after the introduction of the recovery measure. We used a single-case design (N = 1 community mental health team) and hypothesised that clinicians would use recovery-focused language more frequently, and non-recovery-focused language less frequently, following the introduction of the measure, and that these changes would be maintained at 18-month follow-up.

RESULTS

Visual inspection of the data indicated that recovery-focused language increased following the introduction of the HAO, though this was not maintained at follow-up. This pattern was not supported by statistical analyses. No clear pattern of change was found for non-recovery-focused language.

CONCLUSIONS

The introduction of a brief measure of recovery may have influenced staff attitudes and behaviours temporarily. Any longer term impact is likely to depend on ongoing commitment to the use of the measure, without which staff language, attitudes and behaviours return to previous levels.

Tackling community integration in mental health home visit integration in Finland

Integration - and its synonym inclusion - is emphasised in the western welfare states and in the European Union in particular. Integration is also a central topic in the social sciences and in current mental health and homelessness research and practice. As mental healthcare has shifted from psychiatric hospitals to the community, it has inevitably become involved with housing and integration issues. This article explores how community integration is understood and tackled in mental health floating support services (FSSs) and, more precisely, in service user-practitioner home visit interaction. The aim, through shedding light on how the idea of integration is present and discussed in front-line mental health practices, is to offer a 'template' on how we might, in a systematic and reflective way, develop community integration research and practice. The analysis is based on ethnomethodological and micro-sociological interaction research. The research settings are two FSSs located in a large Finnish city. The data contain 24 audio-recorded and transcribed home visits conducted in 2011 and 2012 with 16 different service users. The study shows how the participants in service user-practitioner interaction give meaning to community integration and make decisions about how it should (or should not) be enhanced in each individual case. This activity is called community integration work in action. Community integration work in action is based on various dimensions of integration: getting out of the house, participating in group activities and getting along with those involved in one's life and working life. Additionally, the analysis demonstrates how community integration work is accomplished by discursive devices (resistance, positioning, excuses and justifications, delicacy and advice-giving). The article concludes that community integration is about interaction: it is not only service users' individual challenge but also a social challenge, our challenge.

Stigma resistance is positively associated with psychiatric and psychosocial outcomes: A meta-analysis

To better understand how stigma resistance impacts functioning-related domains, we examined mean effect sizes between stigma resistance and: 1) symptoms (overall, positive, negative, and mood symptoms); 2) self-stigma; 3) self-efficacy; 4) quality of life; 5) recovery; 6) hope; 7) insight, and 8) overall outcomes (the average effect size across the constructs examined in each study). The mean effect size between stigma resistance and overall outcomes was significant and positive (r=0.46, p<0.001, k=48). A large, negative effect size was found between stigma resistance and self-stigma (r=-0.57, p<0.001, k=40). Large, positive effect sizes were found with self-efficacy (r=0.60, p<0.001, k=25), quality of life (r=0.51, p<0.001, k=17), hope (r=0.54, p<0.001, k=8), and recovery (r=0.60, p<0.001, k=7). Stigma resistance had a significant medium and small relationship with insight and symptoms, respectively. Race significantly moderated overall outcomes, self-stigma, mood symptoms, functioning, and hope associations. Education significantly moderated symptoms, functioning, and mood symptoms associations, and age significantly moderated self-stigma and negative symptom associations. Stigma resistance may be a key requirement for recovery. Individual characteristics influence resisting stigma and future work should prioritize cultural factors surrounding stigma resistance.

Psychosis, Socioeconomic Disadvantage, and Health Service Use in South Australia: Findings from the Second Australian National Survey of Psychosis

The association between mental illness and poor physical health and socioeconomic outcomes has been well established. In the twenty-first century, the challenge of how mental illnesses, such as psychosis, are managed in the provision of public health services remains complex. Developing effective clinical mental health support and interventions for individuals requires a coordinated and robust mental health system supported by social as well as health policy that places a priority on addressing socioeconomic disadvantage in mental health cohorts. This paper, thus, examines the complex relationship between socioeconomic disadvantage, family/social supports, physical health, and health service utilization in a community sample of 402 participants diagnosed with psychosis. The paper utilizes quantitative data collected from the 2010 Survey of High Impact Psychosis research project conducted in a socioeconomically disadvantaged region of Adelaide, SA, Australia. Participants (42% female) provided information about socioeconomic status, education, employment, physical health, contact with family and friends, and health service utilization. The paper highlights that socioeconomic disadvantage is related to increased self-reported use of emergency departments, decreased use of general practitioners for mental health reasons, higher body mass index, less family contact, and less social support. In particular, the paper explores the multifaceted relationship between socioeconomic disadvantage and poor health confronting individuals with psychosis, highlighting the complex link between socioeconomic disadvantage and poor health. It emphasizes that mental health service usage for those with higher levels of socioeconomic disadvantage differs from those experiencing lower levels of socioeconomic disadvantage. The paper also stresses that the development of health policy and practice that seeks to redress the socioeconomic and health inequalities created by this disadvantage be an important focus for mental health services. Such health policy would provide accessible treatment programs and linked pathways to illness recovery and diminish the pressure on the delivery of health services. Consequently, the development of policy and practice that seeks to redress the socioeconomic and health inequalities created by disadvantage should be an important focus for the improvement of mental health services.

Tackling Social Cognition in Schizophrenia: A Randomized Feasibility Trial

BACKGROUND

Social cognition difficulties in schizophrenia are seen as a barrier to recovery. Intervention tackling problems in this domain have the potential to facilitate functioning and recovery. Social Cognition and Interaction Training (SCIT) is a manual-based psychological therapy designed to improve social functioning in schizophrenia.

AIMS

The aim of this study is to evaluate the feasibility and acceptability of a modified version of SCIT for inpatient forensic wards. The potential benefits of the intervention were also assessed.

METHOD

This study is a randomized single blind controlled design, with participants randomized to receive SCIT (N = 21) or treatment as usual (TAU; N = 15). SCIT consisted of 8-week therapy sessions twice per week. Participants were assessed at week 0 and one week after the intervention on measures of social cognition. Feasibility was assessed through group attendance and attrition. Participant acceptability and outcome was evaluated through post-group satisfaction and achievement of social goals.

RESULTS

The intervention was well received by all participants and the majority reported their confidence improved. The SCIT group showed a significant improvement in facial affect recognition compared to TAU. Almost all participants agreed they had achieved their social goal as a result of the intervention.

CONCLUSIONS

It is feasible to deliver SCIT in a forensic ward setting; however, some adaptation to the protocol may need to be considered in order to accommodate for the reduced social contact within forensic wards. Practice of social cognition skills in real life may be necessary to achieve benefits to theory of mind and attributional style.

Discrimination against people with severe mental illness and their access to social capital: findings from the Viewpoint survey

Aims. Discrimination against people with severe mental illness is an international problem. It is associated with reduced social contact and hinders recovery. This paper aims to evaluate if experienced or anticipated discrimination is associated with social capital, a known correlate of mental health. Methods. Data from the annual viewpoint cross-sectional survey of people with severe mental illness (n = 1016) were analysed. Exploratory univariate analysis was used to identify correlates of social capital in the sample, which were then evaluated in linear regression models. Additional hypotheses were tested using t tests. Results. Experienced discrimination made a modest contribution to the explained variance of social capital. Experienced discrimination from friends and immediate family was associated with reduced access to social capital from these groups, but this was not found for wider family, neighbours or mental health staff. Experience of discrimination in finding or keeping a job was also associated with reduced access to social capital. Conclusions. Further longitudinal research is needed to determine how resources within people's networks can help to build resilience, which reduces the harmful effect of discrimination on mental health.

Stigma in patients with schizophrenia receiving community mental health care: a review of qualitative studies

PURPOSE

The aim of this review is to identify consistent themes among the qualitative literature on stigma as experienced by patients with schizophrenia receiving community mental health care. With the treatment focus of schizophrenia nowadays shifting more and more towards community-based mental health care, professionals need to be aware of the increased vulnerability of their clients in their social environment as a result of stigma towards their disease. In-depth knowledge on stigma is critical in order to offer a dignifying community mental health care.

METHODS

A systematic search of the qualitative literature in Web of Science, PubMed, PsycINFO and Francis was performed to review the subjective experiences and ideas on stigma in outpatients with schizophrenia.

RESULTS

Three major themes were identified in 18 studies and need to be taken into consideration when implementing an adequate community mental health care: (i) the continuing existence of stigma inherent in the health care setting, (ii) the importance of relational aspects of stigma encounters in daily life and (iii) the significance of the behavioural aspects related to previous stigma experiences and beliefs among patients.

CONCLUSIONS

Despite much effort in community treatment, patients still experience stigma and discrimination. Community mental health care professionals should not only be aware of structural problems in mental health care, but should also pay considerable attention towards the relational and behavioural aspects in their clients' life concerning stigma. Furthermore, they have the crucial role in the community to raise awareness about stigma in order to increase their clients' acceptance in society.

Internalized Stigma of Mental Illness (ISMI) scale: a multinational review

The Internalized Stigma of Mental Illness (ISMI) scale is a 29-item questionnaire measuring self-stigma among persons with psychiatric disorders. It was developed with substantial consumer input and has been widely used, but its psychometric qualities have not been comprehensively evaluated across multiple versions. Here we review the 55 known versions, and provide the 47 available versions, including: Arabic, Armenian, Bengali, Bulgarian, Chinese (Mainland, Taiwan, Hong Kong), Croatian, Dutch, English (USA, South Africa), Estonian, Farsi, Finnish, French, German, Greek, Hebrew, Hindi, Japanese, Khmer, Korean, Lithuanian, Lugandan, Maltese, Polish, Portuguese (Portugal, Brazil), Romanian, Russian, Samoan, Slovenian, Spanish (Spain), Swahili, Swedish, Tongan, Turkish, Urdu, and Yoruba, and qualitative English and Swahili versions, as well as versions for depression, schizophrenia, substance abuse, eating disorders, epilepsy, inflammatory bowel disease, leprosy, smoking, parents and caregivers of people with mental illness, and ethnicity. The various versions show reliability and validity across a wide range of languages, cultures, and writing systems. The most commonly reported findings of studies using the ISMI are that internalized stigma correlates with higher depression, lower self esteem, and higher symptom severity. Initial studies of ways to reduce internalized stigma are promising and warrant further investigation.

Validation of the modified DUKE-UNC Functional Social Support Questionnaire in patients with schizophrenia

PURPOSE

The modified DUKE-UNC Functional Social Support Questionnaire (FSSQ) is considered a psychometric instrument to assess the social support in patients with schizophrenia. However, it has not been validated in this patient population. This issue is addressed here by examining the tool's psychometric properties in a clinical sample of patients with schizophrenia.

METHODS

Two hundred and forty-one patients from ten Adult Mental Health Centres (AMHC) meeting the following inclusion criteria were included: (1) International Classification of Diseases-10 (ICD-10) diagnosis of schizophrenia; (2) Global Assessment of Functioning (GAF) scores ≤50; (3) Illness duration of more than 2 years; and (4) Clinical stability. Patients were evaluated at baseline and at 1-year follow-up for clinical and psychosocial variables.

RESULTS

The factor analysis revealed two factors that explained 54.15 % of the variance. Internal consistency was excellent for the total FSSQ (0.87 at baseline and 0.88 at 1 year follow-up) and ranged between adequate and excellent for FSSQ domains. Correlations between FSSQ scores and those of global functioning, psychiatric symptoms, disability and quality of life ranged between small and large. There were significant differences between groups of patients with schizophrenia in FSSQ scores. Patients with higher levels of somatic complaints and patients who were disabled scored significantly lower in some or all FSSQ scores. After 1-year follow-up, patients improved in overall functioning and there was a decrease in psychiatric symptoms. There were mainly small significant associations between changes in FSSQ scores from baseline to 1-year follow-up and changes in the rest of the test scores, and AMHC visits between baseline and 1-year follow-up.

CONCLUSIONS

The FSSQ scores are reliable and valid, which suggests that the instrument is appropriate for the assessment of perceived social support in patients with schizophrenia.

Cognitive Behavioral Therapy for negative symptoms (CBT-n) in psychotic disorders: a pilot study

BACKGROUND AND OBJECTIVES

The treatment of negative symptoms in schizophrenia is a major challenge for mental health care. One randomized controlled trial found that cognitive therapy for low-functioning patients reduced avolition and improved functioning, using an average of 50.5 treatment sessions over the course of 18 months. The aim of our current pilot study was to evaluate whether 20 sessions of Cognitive Behavioral Therapy for negative symptoms (CBT-n) would reduce negative symptoms within 6 months. Also, we wanted to test the cognitive model of negative symptoms by analyzing whether a reduction in dysfunctional beliefs mediated the effects on negative symptoms.

METHOD

In an open trial 21 adult outpatients with a schizophrenia spectrum disorder with negative symptoms received an average of 17.5 sessions of CBT-n. At baseline and end-of-treatment, we assessed negative symptoms (PANSS) and dysfunctional beliefs about cognitive abilities, performance, emotional experience, and social exclusion. Bootstrap analysis tested mediation.

RESULTS

The dropout rate was 14% (three participants). Intention-to-treat analyses showed a within group effect size of 1.26 on negative symptoms (t = 6.16, | Sig = 0.000). Bootstrap analysis showed that dysfunctional beliefs partially mediated the change.

LIMITATIONS

The uncontrolled design induced efficacy biases. Also, the sample was relatively small, and there were no follow-up assessments.

CONCLUSIONS

CBT-n may be effective in reducing negative symptoms. Also, patients reported fewer dysfunctional beliefs about their cognitive abilities, performance, emotional experience, and social exclusion, and this reduction partially mediated the change in negative symptoms. The reductions were clinically important. However, larger and controlled trials are needed.

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

BACKGROUND

Despite the potential impact on treatment adherence and recovery, there is a dearth of data on the extent and correlates of internalized stigma in patients with schizophrenia in low income countries. We conducted a study to determine the extent, domains and correlates of internalized stigma amongst outpatients with schizophrenia in Ethiopia.

METHODS

The study was a cross-sectional facility-based survey conducted at a specialist psychiatric hospital in Addis Ababa, Ethiopia. Consecutive consenting individuals with a diagnosis of schizophrenia were recruited and assessed using an Amharic version of the Internalized Stigma of Mental Illness (ISMI) scale.

RESULTS

Data were collected from 212 individuals, who were mostly single (71.2%), unemployed (70.3%) and male (65.1%). Nearly all participants (97.4%) expressed agreement to at least one stigma item contained in the ISMI; 46.7% had a moderate to high mean stigma score. Rural residence (OR = 5.67; 95% CI = 2.30, 13.00; p < 0.001), single marital status (OR = 3.39; 95% CI = 1.40, 8.22; p = 0.019) and having prominent psychotic symptoms (OR = 2.33; 95% CI = 1.17, 4.61; p = 0.016) were associated independently with a higher stigma score. Almost half of those who discontinued their treatment reported that they had done so because of perceived stigma. Those who had attempted suicide (45.3%) were more likely to have a high stigma score (OR = 2.29; 95% CI = 1.27, 4.11; p = 0.006). Over 60% of the variation in the experience of stigma was explained by four factors: social withdrawal (16.7%), perceived discrimination (14.1%), alienation (13.9%) and stereotype endorsement (12.7%).

CONCLUSION

Internalized stigma is a major problem among persons with schizophrenia in this outpatient setting in Ethiopia. Internalized stigma has the potential to substantially affect adherence to medication and is likely to affect the recovery process.