Public beliefs about and attitudes towards bipolar disorder: testing theory based models of stigma

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 Thirdly, the under-reporting of negative or nonsignificant results due to publication bias and unpublished studies might have limited the accuracy of this reviews' synthesis.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.

Perceived public stigma and perceived public exposure by persons living with bipolar disorder: A qualitative study

BACKGROUND

Stigma impact the lives of persons living with bipolar disorder.

AIM

The aim of this study was to explore how perceived public stigma is described by people living with bipolar disorder and examine the links between perceived public stigma and perceived public exposure.

METHOD

Face-to-face in-depth interviews were conducted in a purposive sample of euthymic people living with bipolar disorder recruited in a mood disorder ambulatory unit.

RESULTS

Thematic analysis of the transcript yielded five independent themes that were related to perceived public stigma. Perceived public stigma of bipolar disorder was modeled as comprising the three elements of public stigmas (stereotype, prejudice, and discrimination), with the addition of public exposure as a core component.

CONCLUSION

The representation of bipolar disorder in society via newspapers, films/TV series, conferences, and celebrity self-disclosures is considered to have multiple impacts. People living with bipolar disorder have also reported a perceived public stigma of bipolar disorder that has both specific features and characteristics of general mental illness.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Bipolar disorders in Nigeria: a mixed-methods study of patients, family caregivers, clinicians, and the community members' perspectives

BACKGROUND

Bipolar Disorders (BDs) are chronic mental health disorders that often result in functional impairment and contribute significantly to the disability-adjusted life years (DALY). BDs are historically under-researched compared to other mental health disorders, especially in Sub-Saharan Africa and Nigeria.

DESIGN

We adopted a mixed-methods design. Study 1 examined the public knowledge of BDs in relation to sociodemographic outcomes using quantitative data whilst Study 2 qualitatively assessed the lived experiences of patients with BDs, clinicians, and family caregivers.

METHODS

In Study 1, a non-clinical sample of n = 575 participants responded to a compact questionnaire that examined their knowledge of BDs and how they relate to certain sociodemographic variables. One-way ANOVA was used to analyse quantitative data. Study 2 interviewed N = 15 participants (n = 5 patients with BDs; n = 7 clinicians; n = 3 family caregivers). These semi-structured interviews were audio-recorded, transcribed, and thematically analysed.

RESULTS

In Study 1, findings showed no statistically significant differences, suggesting low awareness of BDs, especially among vulnerable populations such as young people and older adults. However, there was a trajectory in increased knowledge of BDs among participants between the ages of 25-44 years and part-time workers compared to other ages and employment statuses. In Study 2, qualitative findings showed that BDs are perceived to be genetically and psycho-socially induced by specific lived experiences of patients and their family caregivers. Although psychotropic medications and psychotherapy are available treatment options in Nigeria, cultural and religious beliefs were significant barriers to treatment uptake.

CONCLUSIONS

This study provides insight into knowledge and beliefs about BDs, including the lived experiences of patients with BDs, their caregivers and clinicians in Nigeria. It highlights the need for further studies assessing Nigeria's feasibility and acceptability of culturally adapted psychosocial interventions for patients with BDs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Danger appraisal and pathogen-avoidance mechanisms in stigma towards severe mental illness: the mediating role of affective responses

BACKGROUND

Stereotypes of dangerousness are common predictors of stigmatising attitudes towards Severe Mental Illness (SMI). However less is known about pathogen avoidance mechanisms underlying stigma towards SMI, specially in samples of non-industrialised societies of Latin America and the Caribbean. The primary aim of this study was to examine pathogen-disgust sensitivity and danger appraisal mechanisms in responses of stigma towards SMI.

METHODS

Cross-sectional design with convenience sampling. Using an online survey, volunteers at the Universidad del Norte in Colombia (N = 271) provided their sociodemographic data and completed the Three-Domain Disgust Scale (TDDS). Participants were randomised to different descriptions of someone with SMI that varied in terms of aggressiveness (with and without danger) and causes of the SMI. Then, following the attribution questionnaire (AQ-27), respondents reported affective and discriminatory responses to the person in the description.

RESULTS

Increased disgust sensitivity to pathogen stimuli resulted in stronger reports of anger (β = .14; p = .03), and fear (β = 0.27; p < 0.001). The relationship between disgust sensitivity and discriminatory responses was indirectly mediated by fear towards SMI (Bootstrapped CI =-.04,-.009). Dangerousness attributions in the description of SMI predicted stronger feelings of anger (β = .23; p = 0.001) and fear (β = .40; p < .001), as well increased support for coercion-segregation of SMI (β = .34; p = 0.04), but less intentions to help (β = -.26; p = 0.003). The relationship between dangerousness and support for coercion was mediated by fear (Bootstrapped CI = .72, 1.37) and anger (Bootstrapped CI = .06, .44), whereas pity (Bootstrapped CI = .03, .38) and fear (Bootstrapped CI = -1.39, -.69) mediated responses of support for coercion-segregation of SMI. Attributions about causes and personal responsibility were not significantly linked to stigma towards SMI (p > 0.05).

CONCLUSIONS

Findings suggested that pathogen avoidance and danger appraisal systems interplay in the generation of discriminatory behaviour towards SMI. Anti-stigma programs and policy makers would benefit from introducing strategies that challenge stereotypes of dangerousness and unpredictability by promoting positive contact with people with SMI.

Internalized-stigma and dissociative experiences in bipolar disorder

INTRODUCTION

Dissociative symptoms have been recently related to bipolar disorder (BD) symptomatology. Moreover, the disease burden carries on a share of perceived self-stigma that amplifies the BD impairment. Internalized stigma and dissociative symptoms often seem overlapping, leading toward common outcomes, with reduced treatment seeking and poor adherence. We hypothesize a potential relationship between dissociation and self-stigma in patients suffering from BD.

MATERIALS AND METHODS

In this cross-sectional study we enrolled a total of 120 adult clinically stable BD outpatients. All participants completed the Internalized Stigma of Mental Illness (ISMI), Dissociative Experiences Scale-II (DES-II), and Manchester Short Assessment of Quality of Life (MANSA).

RESULTS

Average age and age at BD (BD-I n = 66, 55%; BD-II n = 54, 45%) onset were 46.14 (±4.23), and 27.45 (±10.35) years, with mean disease duration of 18.56 (±13.08) years. Most participants were female (n = 71; 59.2%) and 40 (33%) of them experienced lifetime abuse, with an average of 1.05 (±0.78) suicide attempts. DES scores (mean 31.8, ±21.6) correlated with ISMI total-score, with significant association with spikes in Alienation (13.1, SD±3.1) (p < 0.001) and Stereotype (13.8, SD±3.9) (p < 0.001). Linear regression analysis has shown a significant association between DES total score and alienation (p < 0.001), stereotype (p < 0.001) and MANSA total-score (p < 0.001).

DISCUSSION

For the first time, our data suggests that self-stigma is associated to dissociative symptoms, reducing overall quality of life in BD. The early identification of at-risk patients with previous lifetime abuse and high perceived stigma could lead the way for an ever more precise tailoring of treatment management.

The Relationship between Individual-Level and Context-Level Factors and Social Distancing from Patients with Depression in Taiwan: A Multilevel Analysis of National Surveys

Background: Research on social distancing from patients with depression has primarily focused on individual-level factors rather than context-level factors. This study aimed to investigate the relationship between individual-level and context-level factors and social distancing from depressive patients. Methods: Sample data were collected via computer-assisted telephone interviews with 800 Taiwanese adults aged 20 to 65 years in 2016. All effects were tested using multilevel analysis. Results: With regard to individual-level variables, male sex, older age, people with more perceived dangerousness and those with more emotional reaction of fear were associated with greater social distancing from depressive patients. After controlling for individual-level variables, a positive association was found between the degree of urbanization and social distancing. We also found the interaction between the density of psychiatric rehabilitation services and perceived dangerousness to be associated with social distance. This finding revealed that persons with more perceived dangerousness and living in a region with higher density of psychiatric rehabilitation services were associated with greater social distance. Conclusions: We found that social distancing from depressive patients is not only determined by individual-level factors but influenced by the surroundings. This study provides useful directions for the implementation of optimal anti-stigma interventions for patients with depression.

Self-Destigmatization Process? Experiences of Persons Living with Bipolar Disorder: A Qualitative Study

This qualitative study investigated subjective experiences of self-stigmatization and self-destigmatization among people living with bipolar disorder (BD). We conducted in-depth interviews focusing on self-stigmatization and self-destigmatization with 22 individuals living with BD. The interview transcripts were thematically analyzed using a mixed inductive and deductive approach. Thirty-six codes were extracted and organized into six themes: language, behaviors, relationships, personal experience, identity, and healthcare. Each theme was characterized by an evolution process, and the codes were distributed in a step-by-step order as landmarks. The process begins with the experience of self-stigmatization, and develops toward self-destigmatization. This study presents a new six-dimension process called the "self-destigmatization process" (SDP), a personal and interrelational process that deconstructs self-stigmatization. Clinicians can use the landmarks of the process for clinical assessment and therapeutic interventions to increase recovery orientation.

Public beliefs and attitudes toward schizophrenia and depression in Taiwan: A nationwide survey

Beliefs about and attitudes toward mental illness may be influenced by cultural- or country-specific contexts. Through a national survey, the current study investigated beliefs and attitudes toward people with schizophrenia and depression among the general public in Taiwan. A random-digit-dialing telephone-based cross-sectional survey was administered to Taiwanese adults aged 20-64 years (n = 1600). The data were analyzed through binary logistic regressions to test for differences between these disorders in causal beliefs, stereotypes, emotional reactions, desire for social distance, and help-seeking behavior. The results revealed that respondents were more concerned with biogenetic causal explanations for people with schizophrenia than for those with depression. Significantly more respondents perceived people with schizophrenia as more likely to be unpredictable and violent toward others. A similar trend was observed for the desire for social distance. For both disorders, respondents were significantly more likely to express compassion than to express anger toward the person described in the vignette. Respondents also expressed more desire for social distance from someone like the vignette who have received psychiatric treatment. These findings provide useful directions for the implementation of optimal psychoeducation among such communities. .

Public Awareness, Beliefs, And Attitudes Toward Bipolar Disorder In Saudi Arabia

OBJECTIVES

To examine public's knowledge, beliefs, and attitudes toward bipolar disorder (BP) in Saudi Arabia (SA).

METHODS

A cross-sectional survey was performed in 2016 in Riyadh, SA. The survey included sociodemographic characteristics and BP awareness scale.

RESULTS

Of 416 participants, 49.5% had prior knowledge of BP, mainly from internet and social media, and 57% considered it to be common in SA. About half believed BP is caused by a neurophysiological or neurochemical imbalance and that it can be treated with psychiatric medications. Supernatural causes, weak faith, and weakness of character were considered causes of BP by 55%, 48%, and 40% of participants, respectively. Recreational activities and head bandaging by traditional therapists were considered viable treatment options by 55% and 41% of participants, respectively. Students and healthcare professionals scored significantly higher on awareness scale. Regarding attitude, a majority believed that persons with BP can work effectively ‎(86%)‎, have to pull themselves together to get over it (47%), and consider it a shame to mention that someone in a family is affected by BP (32%). Regarding relationships, 22% were not willing to maintain a friendship and 39.3% were not willing to marry someone with BP.

CONCLUSIONS

This study revealed suboptimal public awareness towards BP in SA. It identified several misconceptions and negative attitudes toward patients with BP. Further studies are needed to investigate potential public interventions to improve literacy of BP.

Public stigma of obsessive compulsive disorder and schizophrenic disorder: Is there really any difference?

A substantial delay for help-seeking is a serious problem for people with obsessive-compulsive disorder (OCD), a heterogeneous and debilitating mental health condition. Stigma is a major barrier to treatment seeking and further cause social and occupational impairment. Lack of comprehensive research led us to examine the public's stigmatizing attitudes towards checking, contamination, sexuality, aggression, and religion-related OCD symptoms, compared to schizophrenia. After reading one of six random case vignettes, 621 adults completed social distance scale. Analysis of Covariance or ANCOVA indicated that social distance towards violence and sexuality-related OCD symptoms and schizophrenia did not differ; but social distance for those was higher than religion, contamination, and checking subtypes. Although the contamination vignette did not differ from religion and checking vignettes, the theme of religion had a higher social distance than checking symptoms. Consequently, the current findings imply that there is a difference in public stigma among various symptoms of OCD and symptoms related to sexuality and violence, as well as schizophrenia, are associated with more social rejection. Thus, the general public needs access to educational methods of intervention and contact to eliminate stigma and improve the quality of life for people with mental health disorders.

The development and psychometric properties of the bipolar disorders knowledge scale

PURPOSE

Bipolar Disorder (BD) presents in 1-4% of the world's population, carrying significant financial and functional consequences. Beyond the direct disease burden, patients with BD experience a high degree of both internal and external stigma. Additionally, medication adherence tends to be poor in patients with BD. Knowledge appears to play a role in mitigating both stigma and non-adherence, but these relationships have not been fully elucidated. The Bipolar Disorder Knowledge Scale (BDKS) was designed to explore the role of knowledge and better define such relationships. This research provides the evidence for the reliability and validity of the scale.

METHODS

Forty-seven items were developed to assess knowledge of BD. The 47-item survey was sent out to two groups: first a group of 43 pharmacists with BCPP credentials from the College of Psychiatric and Neurologic Pharmacists (CPNP) who were recruited from the CPNP directory, and second a group of 250 members of the general public who were recruited using Qualtrics Online Sample service. Participants were surveyed on their education status, health literacy, BD diagnostic status, and exposure to patients with BD. Participants then completed the 47-item scale. After 48 h 100 members from the original general public group were sent the same survey to assess test-retest reliability. For each item a difficulty index to evaluate how well participants performed on the item and a discrimination index to determine how well each item performed in high-scorers versus low scorers were calculated. Additionally, Cronbach's alpha was calculated to determine internal consistency validity and a Pearson correlation was run to determine test-retest reliability. Items were removed based on the results from the difficulty index, discrimination index, and Cronbach's alpha. Finally the pharmacist final scores were compared to the general public using an unpaired t-test to assess whether content experts were more likely to perform better on the scale. Following item removal, the scale was finalized at 25-items.

RESULTS

The mean score for the scale was 34.48 (71.83%; SD: 5.50) and the Cronbach's alpha was 0.773 before item analysis. Following item analysis, 22 items were dropped leaving 25 items on the final version of the scale. The remaining items retained a difficulty index below 90% and a discrimination index above 20%. The mean of the 25-item scale was 18.40 (73.6%; SD: 4.13) for the general public and 23.20 (92.8%; SD: 1.36) for the pharmacists group (p < 0.001). The Cronbach's alpha for the finalized scale was 0.760, indicating a high-degree of internal consistency. While this is lower than the original alpha, this may be explained by the reduced number of scale items. A 25-item scale is much more practical and the items on the scale retain stronger item analysis statistics. Finally, the Pearson Correlation for the group who underwent the test-retest procedure was 0.841 (p < 0.001) indicating strong test-retest reliability.

CONCLUSION

The BDKS is a 25-item true-false scale that takes approximately 5-10 min to complete. The scale assesses knowledge of BD with items targeting diagnosis, etiology, disease course, symptoms, treatment, and life impact. The scale has shown strong internal consistency and test-retest reliability in a general population and will be useful for evaluating knowledge of BD as it relates to stigma, non-adherence, and other variables.

Psychological Symptom Amplification: Are Psychological Symptoms Subject to "Somatization"-Like Processes?

Many patients demonstrate amplified somatic symptom experiences that are felt by providers to cause excessive distress and functional impairment, and that can be diagnostically misleading. Terms attached to these presentations include somatization, medically unexplained symptoms, and, most recently, somatic symptom disorder. The analogous amplification of psychological symptoms has not been considered. Accordingly, this column makes a case for discussion and investigation of psychological symptom amplification (PSA), a process made possible by the medical legitimization of certain types of human suffering. As various forms of psychological suffering gain greater medical legitimacy, PSA becomes increasingly relevant. Circumstantial evidence suggests that unrecognized PSA may distort research findings and clinical efficacy in psychiatry. The largely symptom-based nature of psychiatric diagnosis makes PSA a challenging, but necessary, object of further scientific and clinical scrutiny.