Sbaa 181

Schizophrenia Bulletin vol. 47 no. 5 pp.
1261–1287, 2021
doi:10.1093/schbul/sbaa181
Advance Access publication January 18, 2021
Self-stigma in Serious Mental Illness: A Systematic Review of Frequency,

Correlates, and Consequences
Julien Dubreucq*,1–3, , Julien Plasse4,5, and Nicolas Franck1,5,6

1
Centre de Neurosciences Cognitive, UMR 5229, CNRS & Université Lyon 1, Lyon, France; 2Centre référent de réhabilitation
psychosociale et de Remédiation Cognitive (C3R), Centre Hospitalier Alpes Isère, Grenoble, France; 3Fondation FondaMental, Créteil,
France; 4Réseau Handicap Psychique, Grenoble, France; 5Centre Ressource de Réhabilitation Psychosociale et de Remédiation cognitive,
Centre Hospitalier Le Vinatier, Bron, France; 6Pôle Centre Rive Gauche, Centre Hospitalier Le Vinatier, Bron, France
*To whom correspondence should be addressed; Centre référent de réhabilitation psychosociale et de Remédiation Cognitive (C3R),
CH Alpes Isère, 1 place du Conseil National de la Résistance, 38400 Saint Martin d’Hères, France; tel: +33-4-56-58-88-00, e-mail:
jdubreucq@ch-alpes-isere.fr
Self-stigma is associated with poor clinical and functional Introduction

outcomes in Serious Mental Illness (SMI). There has been
For a long time, research on stigma in psychiatric dis-
no review of self-stigma frequency and correlates in dif-
orders focused on public stigma, or the endorsement
ferent cultural and geographic areas and SMI. The object-
of negative beliefs and discriminating attitudes to-
ives of the present study were: (1) to review the frequency,
wards individuals by the general population. Over the
correlates, and consequences of self-stigma in individuals
last two decades, attention has shifted towards the ef-
with SMI; (2) to compare self-stigma in different geograph-
fects of stigma on individuals with Serious Mental
ical areas and to review its potential association with cul-
Illness (SMI). According to Link and Phelan,1 stigma
tural factors; (3) to evaluate the strengths and limitations
involves “elements of labeling, stereotyping, separa-
of the current body of evidence to guide future research.
tion, status loss, and discrimination” that “co-occur in
A systematic electronic database search (PubMed, Web
a power situation that allows the components of stigma
of Science, PsycINFO, Scopus, and Ovid SP Cumulative
to unfold.” The effects of stigma on individuals include
Index to Nursing and Allied Health Literature [CINAHL])
perceived, experienced, anticipated, and self-stigma.
following PRISMA guidelines, was conducted on the fre-
Perceived stigma is defined as one’s beliefs about the at-
quency, correlates, and consequences of self-stigma in SMI.
titudes of the general public towards people with SMI.2
Out of 272 articles, 80 (29.4%) reported on the frequency
Experienced stigma refers to people with SMI’s expe-
of self-stigma (n = 25 458), 241 (88.6%) on cross-sectional
rience of discrimination.3 Anticipated stigma—or the
correlates of self-stigma and 41 (15.0%) on the longitu-
expectation that a person will be discriminated against
dinal correlates and consequences of self-stigma. On av-
because of their SMI—can occur even if the person has
erage, 31.3% of SMI patients reported high self-stigma.
no previous experience of discrimination and contrib-
The highest frequency was in South-East Asia (39.7%)
utes to social withdrawal and self-stigma.3 Self-stigma—
and the Middle East (39%). Sociodemographic and illness-
or internalized stigma—describes the transformation
related predictors yielded mixed results. Perceived and
process wherein a person’s previous social identity (de-
experienced stigma—including from mental health pro-
fined by social roles such as son, brother, sister, friend,
viders—predicted self-stigma, which supports the need
employee, or potential partner) is progressively replaced
to develop anti-stigma campaigns and recovery-oriented
by a devalued and stigmatized view of oneself, known
practices. Increased transition to psychosis and poor clin-
as “illness identity.” 4 Self-stigma occurs when a person
ical and functional outcomes are both associated with self-
moves beyond mere awareness of public stigma and ac-
stigma. Psychiatric rehabilitation and recovery-oriented
tually agrees with it and applies it to themself.2 Stigma
early interventions could reduce self-stigma and should be
resistance is defined as a person’s ability to deflect or
better integrated into public policy.
challenge stigmatizing beliefs.5,6
There is a growing body of evidence—including meta-
Key words: self-stigma/serious mental illness/prevalence analyses—on the effects of self-stigma on people with
/correlates/psychiatric rehabilitation SMI.7–12 In a meta-analysis of 127 articles, Livingston
© The Author(s) 2021. Published by Oxford University Press on behalf of the Maryland Psychiatric Research Center.
All rights reserved. For permissions, please email: journals.permissions@oup.com
1261
J. Dubreucq et al
and Boyd7 reported that most studies were conducted vocational functioning) although this remains to be in-
in Europe or North America (77.5%), and that schizo- vestigated. However, the use of psychiatric rehabilitation
phrenia was the most common diagnosis (54.3%). Self- services also carries the risk of increased labeling and
stigma is frequent in Europe (41.7% of 1229 participants self-stigma.23,24
with schizophrenia and 21.7% of 1182 participants with In summary, three reviews have been conducted on
mood disorders9,10) and North America (36.1% of 144 self-stigma since 2010, in schizophrenia8 and BD.11,12
people with SMI13). Less is known about self-stigma in One meta-analysis investigated the correlates of stigma
other geographic areas. The level of self-stigma might resistance in SMI.6 To our knowledge, there has been
vary according to cultural factors (eg, causal attribu- no review of self-stigma frequency and correlates in dif-
tions of mental illness14) and sociopolitical ideology.15 ferent cultural and geographic areas and for different
According to Yang,14 stigma affects “what matters SMI conditions; nor any specific reviews of self-stigma,
most” in a local social world, by threatening one’s ca- excluding explicitly perceived or experienced stigma.
pacity to meet social expectations (eg, the ability to en- The effects of nonspecific recovery-oriented practices on
gage in key life activities such as work or marriage14,16) self-stigma remain unknown. Based on the literature, we
and the whole family’s moral standing and socioec- would expect to find a higher frequency of self-stigma
onomic status. Self-stigma might be more common in in Eastern countries compared with Western countries.
non-Western countries than in Western countries but We made the hypotheses that cultural factors would in-
this remains unproven. fluence self-stigma and that self-stigma would be associ-
Compared with those with nonpsychotic disorders, ated with poor recovery-related outcomes. The present
people at risk of psychosis face higher levels of public review has three objectives: (1) to review the frequency,
stigma that can lead to self-stigma.17,18 People with BPD correlates, and consequences of self-stigma in individ-
are prone to self-criticism and feelings of shame that uals with SMI; (2) to compare self-stigma in different
can make them more vulnerable to self-stigma.19 They geographical areas and to review its potential associa-
face high levels of stigma, not only from the general tion with cultural factors; (3) to evaluate the strengths
public but also from mental health professionals.20 and limitations of the current body of evidence to guide
Gerlinger8 reported in a systematic review on stigma in future research.
schizophrenia the lack of studies comparing stigma at
different stages of illness. It is still unclear whether self-
Methods
stigma is greater in cases of prolonged psychosis com-
pared with early psychosis, at-risk stages, or other SMI A stepwise systematic literature review (PRISMA guide-
diagnoses. lines)25 was conducted by searching PubMed, Medline,
To date, there have been no literature reviews com- Web of Science, PsycINFO, the Scopus citation index, and
paring self-stigma frequency and correlates in different Ovid SP Cumulative Index to Nursing and Allied Health
geographical and cultural areas (Europe, North America, Literature (CINAHL) for published, peer-reviewed articles
South America, Middle East, South Asia, South-East using the following keywords: “schizophrenia” / “bipolar
Asia, and Oceania). Similarly, to our knowledge, no liter- disorder” / “borderline personality disorder” / “major de-
ature review has been conducted comparing internalized pression” / “depression” / “anxiety disorder” / “serious
stigma in at-risk stages, schizophrenia, BD, MDD, BPD, mental illness” AND “stigma” / “self-stigma” / “intern-
and anxiety disorders. Self-stigma was negatively associ- alized stigma”/ “internalised stigma.” No time restriction
ated with self-esteem, self-efficacy, quality of life (QoL), was set. Only published articles in English or French were
and clinical and functional outcomes.7 However, it is dif- included in the review. The reference list of three meta-
ficult to disentangle the specific effects of self-stigma, as analyses6,7,26 and three literature reviews8,11,12 on stigma
measures of perceived or experienced stigma are often and schizophrenia or BD were screened for additional
used to assess the correlates of self-stigma (43.9% of the relevant articles. To be included in this review articles had
127 studies7). Most studies were cross-sectional (86.7% to meet all of the following criteria: (1) report explicitly
of 127 studies7). The longitudinal effects of self-stigma on self-stigma (ie, articles on public stigma or using meas-
remain largely unknown. Several interventions (combin- ures of perceived or experienced stigma were excluded);
ations of psychoeducation and cognitive restructuring in (2) concern a diagnosis of schizophrenia, bipolar disorder,
most cases, making empowered decisions about disclo- borderline personality disorder, major depression or anx-
sure in others) have been designed to reduce self-stigma iety disorders; (3) provide quantitative data on the prev-
and its impact on patients’ outcomes.21 Psychiatric re- alence, correlates, or consequences of internalized stigma
habilitation brings together a wide range of recovery- or stigma resistance. The first author applied the eligibility
oriented interventions.22 Psychiatric rehabilitation could criteria and screened the records to select the included
indirectly reduce self-stigma (eg, through improved psy- studies. The last author reviewed each decision. Disputed
chiatric symptoms, self-esteem, cognitive, social, and items were solved through discussion and by reading the
1262
Frequency, Correlates, and Consequences of Self-stigma in Serious Mental Illness
article in detail to reach a final decision. For each study, (figure 1). See supplementary table 5 for the list of the
we extracted the following information: general informa- excluded studies.
tion (author, year of publication, country, design, popu- The 272 articles included were characterized by the
lation considered, setting, total number of participants, heterogeneity of the samples, methods, scales, and re-
mean age, or age range), outcome measure (scale/items ported outcomes. Most were published after 2010 (244
used to measure self-stigma, reliability), the main findings, studies; 89.7%) and used cross-sectional designs (231
and variables relating to quality assessment (see supple- studies; 84.9%) with only 41 studies (15.1%) reporting
mentary table 2 for the detailed characteristics of the in- longitudinal outcomes. A total of 89 (95 studies (34.9%)
cluded studies). Quality assessment was performed using were conducted in Europe, 76 (27.9%) in North America,
the Systematic Appraisal of Quality in Observational 44 in South-East Asia (16.2%), 24 (8.8%) in the Middle
Research (SAQOR) tool. This tool comprises six domains East, 13 (4.8%) in Africa, 10 in South Asia (3.7%), 4 in
(sample, control/comparison group, exposure/outcome South America (1.5%), 4 in Oceania (1.5%), and 2 studies
measurements, follow-up, confounders, and reporting of (0.7%) compared internalized stigma in different geo-
data27) and has been adapted for cross-cultural psychiatric graphical areas (see supplementary table 1 for the geo-
epidemiology studies.28 An overall quality score (high, graphical distribution of the included studies).30,31 Most
moderate, or low) was determined based on adequacy in studies included outpatients (211 studies, 77.6%). A total
the six domains. Means and percentages were weighted for of 30 studies (11.3%) were conducted in a psychiatric
the number of cases per study to obtain prevalence data. rehabilitation context, 5 studies (1.8%) in consumer-
Derived weighted means by geographical area and pooled operated service programs or advocacy groups and 6
standard deviations were calculated. One-way ANOVA was studies (2.2%) in prison settings.
conducted from these summary data and post hoc pairwise A total of 114 studies (41.9%) concerned schizo-
test comparisons were computed using the Tukey–Kramer phrenia, 14 (5.1%) BD, 13 (4.8%) MDD, and 13 (4.8%)
method. Weighted scores were calculated using propor- at-risk stages or first episode psychosis, 2 (0.7%) anxiety
tions of rating scale scores. The frequency of self-stigma disorders and 1 obsessive-compulsive disorder (0.4%).
is often measured using the Internalized Stigma of Mental A total of 115 studies (42.3%) looked at SMI. There
Illness Scale.29 A score above the midpoint indicates a were large variations in the definition of SMI. Twenty-
moderate to high level of self-stigma.9,29 This choice was five studies (9.6%) defined SMI as schizophrenia, BD, or
made for practical reasons (ie, facilitating comparisons be- MDD. Fifty-four studies (20%) used a broad definition
tween the studies) as there is no valid cutoff for measuring of SMI and included participants with anxiety disorders
self-stigma. Stigma resistance is often measured using the (AD, n = 25), obsessive-compulsive disorder (n = 11),
ISMI stigma resistance subscale, which shows variable in- and personality disorders (13 studies). Twelve studies
ternal consistency (0.56 in Firmin et al meta-analysis6). (4.6%) investigated self-stigma in schizophrenia and BD
Only the studies reporting internal consistency of above (n = 6), schizophrenia and MDD (n = 1), mood disorders
0.50 were considered when extracting the correlates of (n = 2), schizophrenia and AD (n = 1), AD and MDD
stigma resistance. The study protocol was registered on the (n = 1), and BPD and social phobia (n = 1). Twenty-
PROSPERO database on July 4, 2019 (ID 141282). four studies (8.1%) did not specify the different forms of
SMI. Most studies included young (18–34 years old; 50
Results studies [18.4%]) or middle-aged participants (35–50 years
old; 185 studies [68%]). See supplementary table 6 for the
Our search on July 5, 2019 found 3215 articles on characteristics of studies that included people less than 18
PubMed and 11 472 on Web of Science. It was com- years old. One hundred and ninety-two studies (70.6%)
pleted by searching PsycINFO, the Scopus citation used the Internalized Stigma of Mental Illness29 scale to
index, and Ovid SP CINAHL on March 25, 2020 then measure internalized stigma and 33 studies (12.1%) the
updated on April 16, 2020. The search was completed on Self-Stigma of Mental Illness Scale32 (SSMI). Forty-seven
August 22, 2020 using the additional terms “psychosis,” studies (17.3%) measured self-stigma with other scales.
“depression,” “internalized stigma,” and “internalised Most of the instruments used to measure self-stigma in
stigma.” This resulted in 5371 supplementary articles. non-Western countries were adaptations of scales de-
After manually removing all duplicates, there were 4250 signed in Europe or North America (n = 74; 80%). The
remaining references. Based on their titles and abstracts, quality ratings of the included studies obtained using
3811 articles were excluded for lack of relevance. Most SAQOR27 ranged from high to moderate (respectively,
of these articles focused on public stigma, perceived or 57.7% and 42.3%). The results are shown in table 1.
experienced stigma, or self-stigma in other discriminated
populations. Our search strategy yielded 429 full-text ar-
ticles. After conducting a full-text analysis of all these Frequency of Self-stigma
articles and excluding those which did not meet the in- Eighty articles (29.4%) reported data on self-stigma extent
clusion criteria, we ended up with 272 relevant articles in SMI, or on the proportion of individuals with moderate
1263
J. Dubreucq et al
Fig. 1. Review process (Prisma flow diagram)
to high self-stigma, or on both outcomes. Thirty-three schizophrenia (35.8%). Higher frequency was found in
studies were conducted in Europe, 20 studies in North South-East Asia and the Middle East for SMI, and in
America, 17 in South-East Asia, 9 in Africa, 12 in Middle North America, Europe, and Africa for schizophrenia.
East, 6 in South Asia, 1 in South America, 1 in Australia, Significant between-group differences in mean self-stigma
and 1 in Austria and Japan. Nine studies compared the fre- scores were found between Europe and South Asia or
quency of self-stigma in different countries,9,10,30,33,34 cities,35 South-East Asia for participants with SMI (P < 0.001;
or settings.13,36,37 The samples were mostly composed of in- weighted mean difference = 0.150 and 0.140), schizo-
dividuals with schizophrenia (31 studies; 43.4%) or SMI phrenia (P < 0.001; 0.159 and 0.143), bipolar disorder
(33 studies; 40.5%). The results are shown in table 2. Forty- (P < 0.001; 0.253 and 0.35), and MDD (P < 0.001; 0.148
seven articles reported on the proportion of moderate to and 0.07). Compared with Europe, self-stigma was higher
high self-stigma (ISMI >2.5 or above the midpoint on other in the Middle East and Africa for SMI (P < 0.001; 0.322
scales) in a total of 15 871 participants (7500 SMI, 5518 and 0.140) and in the Middle East and South America
schizophrenia, 1582 BD, 1188 MDD, 64 BPD, 19 AD). for schizophrenia (P < 0.001; 0.401 and 0.08). Box plots
Eighty-five articles documented self-stigma extent (ISMI on the differences by geographical area are provided on
mean total score and standard deviation) in 25 458 parti- table 3. Self-stigma did not differ between South-East Asia
cipants (11 028 with SMI, 9661 with schizophrenia, 2083 and Africa for SMI, South Asia and South-East Asia for
with BD, 2154 with MDD, 377 with AD, 155 with BPD). schizophrenia, and North America and the Middle East
About one-third of people with SMI (31.3%) reported for bipolar disorder. The results are shown in supple-
elevated self-stigma. The highest frequency was found in mentary table S4. There were significant country-related
1264
Table 1. Research Characteristics of the 272 Studies Included in were found for schizophrenia, BD (18.5% Turkey,41 in
the Review remitted BD; 26% USA,42 in non-adherent BD), MDD,
obsessive-compulsive disorder and anxiety disorders.
All studies
Characteristic (n = 272) %
Cross-sectional Correlates of Self-stigma
Publication date
Pre 2011 28 (10.3%) Two hundred and forty-one studies (88.6%) reported on
2011 or later 244 (89.7%) cross-sectional internalized stigma correlates. The most
Study design common diagnosis was schizophrenia (n = 106; 44%), fol-
Cross-sectional 231 (84.9%) lowed by BD (n = 11; 4.6%) and at-risk states or early
Longitudinal 41 (15.1%) psychosis (n = 9; 3.7%). Ninety studies (37.3%) concerned
Region of study
North America 76 (27.9%) SMI. The results are shown in table 4. See supplementary
Europa 95 (34.9%) table 3 for the detailed list of correlates/consequences.
South Asia 10 (3.7%) Few sociodemographic characteristics correlated signif-
South East Asia 44 (16.2%) icantly with self-stigma. Immigrant status, history of in-
Middle East 24 (8.8%) carceration or homelessness,36,43 parenting status (mothers
South America 4 (1.5%)
Africa 13 (4.8%) > fathers44), shame proneness, and avoidant or self-de-
Australia 4 (1.5%) feating personality traits (n = 6 studies) were associated
Others 2 (0.7%) with higher self-stigma. The results were contrasted for all
Study sites other sociodemographic variables (age, gender, education
Single site 270 (99.3%) level, employment, marital status, income, and source of
Multiple countries/sites 2 (0.7%)
Diagnosis income). Other personal characteristics (attachment style,
Severe mental illness 115 (42.3%) self-compassion) were not associated with self-stigma.45,46
Bipolar disorder 14 (5.1%) Residual psychiatric symptomatology, positive and nega-
Obsessive-compulsive disorder 1 (0.4%) tive symptoms for schizophrenia, and depressive symptoms
Major depressive disorder 13 (4.8%) for BD were associated with higher self-stigma in most
Anxiety disorder 2 (0.7%)
Schizophrenia 114 (41.9%) studies (84.6% significance; n = 65). Social anxiety (n = 3)
At risk stages/first episode psychosis 13 (4.8%) and distress from sub-threshold psychotic symptoms47
Mean age were positively correlated with self-stigma. Self-stigma
<18 years old 3 (1.1%) was equally severe in participants with ultra-high risk and
18–34 years old 50 (18.4%) established psychosis.48 Internalized shame about mental
35–50 years old 185 (68%)
>50 years old 13 (4.8%) illness and fear accuracy in an emotion recognition task
Mixed 21 (7.7%) were negatively associated in people at risk of psychosis.49
% articles including people <18 Stigma stress, identified as a predictor of self-stigma in
Yes 24 (8.8%) several studies (n = 4), was positively associated with tran-
No 248 (91.2%) sition to psychosis.50 Comorbid post-traumatic stress dis-
Internalized stigma measures
Internalized Stigma of Mental Illness (ISMI) 192 (70.6%) order (n = 2) and an increased number of drug side effects
Self-Stigma of Mental Illness Scale (SSMIS) 33 (12.1%) (n = 4) were positively associated with self-stigma.
Others 47 (17.3%) Public stigma51 and other dimensions of stigma were
Patient status associated with self-stigma (perceived stigma, n = 18
Inpatient 28 (10.3%) studies; perceived stigma from mental health providers,52
Outpatient 211 (77.6%)
Mixed 32 (11.8%) n = 1; experienced stigma, n = 9; anticipated stigma,
Not reported 1 (0.3%) n = 3). Cultural factors such as attributing mental illness
Psychiatric rehabilitation to supernatural causes,53–55 a history of traditional treat-
Yes 47 (17.3%) ment,53,55 and loss of face in Eastern countries35,56 were as-
No 225 (82.7%) sociated with self-stigma. Concerns about losing face (or
Quality rating
High 157 (57.7%) the fear of losing face because of being diagnosed with
Moderate 115 (42.3%) SMI) mediated the relationship between perceived stigma
and self-stigma.56 Stigma stress (n = 4) and negative emo-
tional reactions to involuntary psychiatric admission57,58
differences in the proportion of people with SMI who were significant correlates of self-stigma, in contrast with
reported high self-stigma in Europe (from 15.2% in compulsory community treatment,37 forensic status,36 and
Sweden9 to 57% in Croatia33), North America (from 9% the number of involuntary admissions.57–59 In-group value
in Canada37 to 37% in USA38) and in South-East Asia (ie, how people with SMI see their own group,60 social
(from 8.1% in South Korea39 to 50% in Taiwan40). Setting- networks and support (n = 11; n = 21), membership of
related differences were also found.13,35 Similar variations an advocacy group, and family support protected against
1265
Table 2. Frequency of Internalized Stigma
1266
Area Study Country N Mean IS total score SD n High IS (%)
Europe SMI Evans-Lacko51 Multi-site 1835 2.2 0.5 - -

Grambal169 Czech Republic 184 2.19 0.5 - -
J. Dubreucq et al
Rusch58 Switzerland 186 1.9 0.6 - -

57
Xu Switzerland 141 1.91 0.61 - -
170
Kamaradova Czech Republic 332 2.10 0.5 - -
Bradstreet45 UK 272 2.2 0.49 - -
33
Krajewski Multi-site 786 2.29 (1.96–2.71) 0.5 786 33% (15.2%–57.4%)
93
Dubreucq France 738 2.20 0.51 738 31.2%
96
Oexle Switzerland 222 2.10 0.55 - -
107
Rusch Switzerland 116 2.15 0.54 - -
Szczesniak171 Poland 114 2.23 0.5 - -
Weighted total 4926 2.18 0.26 1524 32%
9
Schizophrenia Brohan Multi-site 1129 2.40 (2.0–2.97) 0.56 1129 41.7%
126
Vidovic Croatia 149 2.13 0.93 149 22.8%
172
Sibitz Austria 157 2.09 0.67 - -
Galderisi173 Italia 921 2.1 0.5 - -
174
Rossi Italia 910 2.2 0.44 - -
81
Aukst-Margetic Croatia 117 2.13 0.44 - -
30
Hofer Austria 52 2.01 0.51 - -
Bouvet175 France 62 2.23 0.46 - -
Vrbova176 Czech Republic 197 2.18 0.46 - -
177
Surmann Germany 80 2.12 0.47 - -
93
Dubreucq France 466 2.18 0.51 466 29.8%
178
Holubova Czech Republic 103 2.20 0.47 - -
Szczesniak171 Poland 51 2.19 0.5 - -
Uhlmann179 Germany 23 2.0 0.5 - -
176
Vrbova Czech Republic 197 2.18 0.47 - -
83
Switaj Poland 110 2.39 0.53 - -
Table 2. Continued

Weighted total 4724 2.21 0.27 1744 36.9%
10
Bipolar disorders/MDD Brohan Multi-site 577 1.94 BD 1.97 0.87 1182 21.7%
603 2.11 MDD
180
Bipolar disorders Post Austria 60 1.9 BD 0.57 - -
Dubreucq93 France 117 2.2 0.53 117 29.9%
Quenneville181 Switzerland 69 2.27 0.5 - -
171
Szczesniak Poland 19 2.39 0.5 - -
182
MDD Lanfredi Multi-site 516 2.2 0.5 - -
93
Dubreucq France 27 2.29 0.56 27 40.7%
Holubova178 Czech Republic 80 1.96 0.42 - -
95
Prasko Czech Republic 72 2.36 0.49 - -
171
Szczesniak Poland 42 2.46 0.6 - -
Weighted total BD 842 2.01 0.60 1326 22.7%
MDD
1340 2.16 0.47
Anxiety disorders Ociskova183 Czech Republic 109 2.24 0.49 - -
169
Grambal Czech Republic 37 1.98 0.54
93
Dubreucq France 19 2.35 0.56 19 42.1%
184
OCD Moritz Germany 50 1.99 0.48 - -
Weighted total - 215 2.14 - 19 42.1%
BPD Grambal169 Czech Republic 35 2.45 0.50 - -
93
Dubreucq France 64 2.36 0.47 64 43.8%
181
Quenneville Switzerland 39 2.56 0.66 - -
170
Personality disorder Kamaradova Czech Republic 17 2.37 0.58 - -
Weighted total - 155 2.43 - 64 43.8%
North America SMI Livingston36 Canada 91 2.13 0.38 91 10%
Livingston37 Canada 71 2.10 0.35 71 9%
Livingston43 Canada 94 2.22 0.49 94 23.4%
West13 USA 144 1.72 0.57 144 36.1% (31%–41%)
Ritscher-Boyd112 USA - - - 82 28%
Ritscher-Boyd185 USA 149 2.19 0.52 149 24.8%
Drapalski186 USA 100 2.3 0.4 100 35%
Harris38 USA 235 2.31 0.47 235 37%
Chronister187 USA 101 2.2 0.45 101 25%
1267
Table 2. Continued
1268
188
Kira USA 330 2.16 0.72 330 40.1%
Tomar189 USA 108 2.31 0.5 108 40.7%
J. Dubreucq et al
Pearl105 USA 319 2.11 0.53 - -

Jahn190 USA 516 2.25 0.49 - -
Villotti191 USA 170 1.95 0.47 - -
Weighted total - 2428 2.16 1505 31.4%
Schizophrenia Firmin192 USA - - - 111 36.5% (25%–45%)
O’Connor133 USA - - - 353 50%
Link193 USA - - - 65 26.2%
Lysaker101 USA 70 2.36 0.54
Weighted total - 70 2.36 0.29 529 44.2%
Bipolar disorders Howland42 USA 115 2.22 0.48 115 26%
Bassirnia194 USA 112 1.94 0.47 - -
Weighted total 227 2.08 0.22
South America Schizophrenia Caqueo-Uritzar34 Multi-site 253 2.3 0.54 253 38.6% (28.6%–48.7%)
Australia Schizophrenia Hill195 Australia 60 2.56 0.49 - -
South Asia SMI Grover196 India 1,403 2.29 0.47 1403 29.4%
Maharjan197 Nepal - - - 180 52%
Weighted total - 1403 2.29 0.22 1583 28.6%
Schizophrenia Grover196 India 707 2.37 0.51 707 37.9%
Singh198 India 100 2.3 0.40 100 29%
Pal199 India 32 2.74 0.40 - -
Weighted total - 839 2.37 0.24 807 36.8%
Bipolar disorders Grover196 India 344 2.23 0.38 344 20.6%
Pal199 India 59 2.25 0.38 - -
Grover200 India 185 2.33 0.43 185 28%
Weighted total - 588 2.26 0.15 529 23.2%
MDD Grover196 India 352 2.19 0.45 352 21%
Sahoo201 India 107 2.39 0.57 107 40.1%
Weighted total - 459 2.23 0.23 459 25.5%
Anxiety disorders Pal199 India 30 1.97 0.37 - -
South-East Asia SMI Picco202 Singapore 280 2.37 0.54 280 43.6%
Ho97 China 136 2.3 0.6 136 36.8%
Young35 China 474 2.42 (2.34–2.50) 0.52 474 43.5% (38.3%–49.5%)
Kim39 South Korea 160 2.06 0.36 160 8.1%
Kao40 Taiwan 251 2.26 0.51 251 50%
Weighted total - 1301 2.32 0.26 1301 39.7%
Schizophrenia Lv138 China 95 2.17 0.38 95 20%
Hsiao61 Taiwan 111 2.33 0.53 111 27%
Lien76 Taiwan 170 2.36 0.52 170 39.4%
Kao40 Taiwan 151 2.42 0.44 151 51%
Li139 China 384 2.30 0.39 - -
Hofer30 Japan 60 2.16 0.42 - -
Ran127 China 232 2.46 0.28 - -
Table 2. Continued

Mak67 China 162 2.34 0.61 - -
Shin88 South Korea 70 2.11 0.53 - -
Pribadi203 Indonesia 300 2.5 0.94 300 34%
Picco202 Singapore 74 2.41 0.52
Kim204 South Korea 123 2.15 0.50 - -
Lu205 China 92 2.11 0.45 - -
Park206 South Korea 321 2.51 0.65 - -
Weighted total - 2345 2.36 0.32 827 32.4%
Bipolar disorder Ran127 China 39 2.36 0.30 - -
Weighted total 2.36 0.09
MDD Picco202 Singapore 74 2.44 0.55 - -
Woon207 Malaysia 99 2.0 0.6 99 23.2%
Ran127 China 182 2.43 0.28 - -
Weighed total 355 2.31 0.20 99 23.2%
Anxiety Disorders Picco202 Singapore 71 2.23 0.56 - -
OCD Picco202 Singapore 61 2.41 0.49 - -
Weighted total - 132 2.31
Middle East SMI Ghanean208 Iran - - - 138 39%
Tanriverdi209 Turkey 217 2.59 0.33 - -
Hasson-Ohayon210 Israel 107 2.28 0.49 - -
Korkmaz211 Turkey 224 2.53 0.48 - -
Schizophrenia Sarisoy41 Turkey 109 2.17 0.51 109 29.4%
Çapar212 Turkey 250 2.76 0.37 - -
Olçun213 Turkey 76 2.51 0.55 - -
Yilmaz214 Turkey 63 2.63 0.49 - -
Yildirim94 Turkey 200 2.74 0.46 - -
Tanriverdi209 Turkey 46 2.54 0.25
Weighted total - 744 2.61 0.32 109 29.4%
Bipolar disorders Sarisoy41 Turkey 118 2.10 0.46 118 18.5%
Cerit215 Turkey 80 2.12 0.39 - -
Sadighi216 Iran 126 1.90 0.87 126 27.6%
Tanriverdi209 Turkey 63 2.52 0.32 - -
Weighted total - 387 2.10 0.35 244 19.2%
Africa SMI Adewuya217 Nigeria - - - 340 21.6%
Girma53 Ethiopia 422 2.32 0.30 422 25.1%
Ibrahim55 Nigeria - - - 370 22.5%
Asrat218 Ethiopia - - - 317 32.1%
Weighted total 422 2.32 0.09 1449 25.1%
Schizophrenia Mosanya125 Nigeria 256 1.94 0.68 256 18.8%
Fadipe219 Nigeria 370 2.09 0.43 370 16.5%
Assefa220 Ethiopia - - - 212 46.7%
Bifftu124 Ethiopia - - - 411 48.6%
Weighted total - 626 2.03 0.29 1249 32.6%
Note: MDD, Major Depressive Disorder; OCD, Obsessive Compulsive Disorder; BPD, Borderline Personality Disorder; SMI, Severe Mental Illness. Mean Internalized Stigma
refers to ISMI mean total score. High Internalized Stigma refers to the proportion of patients with ISMI > 2.5 or above the midpoint on other scales. Bold faces represents the
total sample and the weighted means and proportions.
1269
J. Dubreucq et al
Table 3. Between-groups Differences by Geographical Area
Serious Mental Illness
Schizophrenia
1270
Table 3. Continued
Bipolar Disorder
Major depressive disorder
Means and percentages were weighted for the number of cases per study to obtain prevalence data. Derived weighted means by geographical area
and pooled standard deviations were calculated. One-way ANOVA was conducted from these summary data and Post hoc pairwise test compari-
sons were computed with Tukey–Kramer method. Plots shows the ISMI mean score for each studies and each area with 95% confidence interval.
1271
J. Dubreucq et al
self-stigma.61,62 Family expressed emotion and associative included participants with SMI (n = 15; 36.6%), schiz-
stigma in mental health professionals were associated ophrenia (n = 16; 39%) or at-risk stages/early psychosis
with higher self-stigma.63,64 Self-stigma mediated the ef- (n = 5; 12.2%). Twelve studies included young partici-
fects of family expressed emotion and in-group value on pants (<18, n = 1; 18–35, n = 11) and three individuals
psychosocial function and personal recovery.64,65 over 50 years old (10.7%). Fifteen were conducted in psy-
Insight into illness (n = 32 studies), parental insight,66 chiatric rehabilitation settings (36.5%). The duration of
self-perception of clinical severity (n = 3), perceived cog- follow-up ranged from 6 weeks95 to 2 years.96 The results
nitive dysfunction (n = 4), and attributions of personal are shown in table 5.
responsibility67 were associated with higher self-stigma. Fifteen studies reported on the baseline factors
Impairments in cognitive and metacognitive function influencing the level of self-stigma at follow-up. Residual
(n = 5; n = 7), dysfunctional attitudes68 and avoidant psychiatric symptoms,97–100 negative emotional reactions
coping strategies (n = 8) were associated with higher to involuntary hospitalization,57,99 and emotional dis-
self-stigma. Conversely preserved cognitive abilities,69–71 tress98,101 were the most significant baseline factors associ-
empowerment, self-efficacy, self-agency, and stigma re- ated with self-stigma at follow-up. Duration of untreated
sistance protected against self-stigma.9,10,62,72 Mixed re- psychosis97 and baseline coping strategies102 were associ-
sults were found for other illness-related correlates (age ated with higher self-stigma in single studies. Mixed re-
of onset, psychiatric diagnosis, illness duration, history sults were found for self-stigma stability over time with
of suicide attempts, inpatient status, past psychiatric ad- no specific intervention.86,102–104 Attending psychiatric
mission, and number of hospitalizations). rehabilitation was associated with significant reductions
In general, self-stigma was positively associated with in self-stigma extent (from a mean total ISMI score of
depressive symptoms (n = 41) and suicidal ideation 2.31 on admission to 1.96 at discharge; 38 2.36–2.20; 101
(n = 14) and negatively correlated with hope (n = 19), 2.11–1.96; 105 2.1–2.04; 106 1.80–1.50 in participants having
help seeking (n = 5), and treatment adherence (n = 15). worked in the past year without being discriminated
Single studies found negative associations with thera- against107) and in the proportion of participants with
peutic alliance73 and shared decision making.74 Insight high self-stigma (ISMI > 2.5 from 37% to 13.7%; 38 re-
into illness,70,75–80 avoidant personality traits,81 and coping duction in ISMI levels at follow up > 25% in 38% of the
strategies,82 loneliness,83 and resilience84 moderated the participants with mean self-stigma > 2103). Not receiving
relationship with depression and self-esteem mediated disability benefits during psychiatric rehabilitation was
the effects of self-stigma on hope.85 Self-stigma mediated associated with a greater reduction in self-stigma.38
the effects of perceived cognitive dysfunction and expe- Attending consumer-operated service programs was as-
rienced stigma on suicidality86,87 and QoL.88 Self-stigma sociated with self-stigma reduction.108
was negatively associated with QoL (n = 41), self-es- Twenty-eight studies reported on the longitudinal con-
teem (n = 44), self-efficacy (n = 13), well-being (n = 9), sequences of self-stigma. Self-stigma at baseline was as-
life satisfaction (n = 8), empowerment (n = 11), resilience sociated with increased positive symptoms,109 emotional
(n = 7), stigma resistance (n = 11), and personal recovery discomfort,100 social anxiety,110 depression,111,112 suicidal
(n = 22). Self-stigma positively correlated with the “why ideation,96,113 and an increased risk of psychiatric hos-
try effect” 89 and later stages of self-stigma with a higher pitalization114 at follow-up. Participants with high self-
impact on hope, self-esteem, psychosocial function, and stigma reported reduced self-esteem,112 decreased life
personal recovery.89,90 Participants in the late stages of satisfaction,115 lower personal recovery,116 less use of
self-stigma reported more reasons for not disclosing their adaptive coping strategies,102 and lower treatment ad-
psychiatric diagnosis, in contrast with those in the early herence117 at follow-up. Baseline self-stigma was associ-
stages who reported greater benefits from being “out”.91 ated with poorer social and vocational functioning109,118
Self-stigma was negatively associated with global func- at follow-up, and less benefits from vocational reha-
tioning (n = 27). Higher demoralization and decreased bilitation.119 A change in self-stigma during follow-up
resilience mediated the relationship between self-stigma predicted depression. Increases in self-stigma were asso-
and psychosocial function.75,92 Self-stigma was negatively ciated with more depressive symptoms109 and higher sui-
associated with relational satisfaction.41,93 Self-stigma cidality.99,120 Decreases in self-stigma were associated with
positively correlated with sense of loneliness,83,94 fear of less depression.104,105 Increased self-stigma was associated
intimate relationships,41 and self-stigma on parenting with more negative attitudes towards psychiatric medica-
abilities for mothers living without their children.44 tion,120,121 poorer social function,122 reduced self-esteem,99
and lower personal recovery.116 Reduced self-stigma was
associated with decreased subjective clinical severity,105
Self-stigma and Longitudinal Outcomes higher self-esteem,101 and improved global functioning.105
Forty-one studies reported longitudinal outcomes as- Baseline self-stigma was not associated with QoL at fol-
sociated with internalized stigma. These studies mainly low-up.37 Decreased self-stigma during follow-up was,
1272
Table 4. Cross-sectional Correlates and Consequences of Self-stigma
A B C D E
Non-
Number significant Significant Positive re- Negative re-
of studies relationship relationship lationship lationship
(n = 272) (P > 0.05) (P < 0.05) (P < 0.05) (P < 0.05)
Variables n % n % n % n % n %
Sociodemographic
Gender (1) 62 22.8 50 80.7 12 19.3 3 25.0 9 75.0
Age 68 25.0 49 72.1 19 27.9 12 63.2 7 36.8
Education 60 22.1 37 61.7 23 38.3 10 43 13 57
Employment(2) 37 13.6 16 43.2 21 56.8 2 9.5 19 90.5
Marital status(3) 40 14.7 28 70 12 30 3 25.0 9 75.0
Income 16 5.9 5 31.2 11 68.8 0 0 11 100
Source of income (4) 11 4.0 6 54.5 5 45.5 3 60 2 40
Immigrant status 1 0.4 0 0 1 100 1 100 0 0
History of incarceration/homelessness 2 0.7 0 0 2 100 2 100 0 0
Experience of victimization 2 0.7 0 0 2 100 2 100 0 0
Parenting status (5) 2 0.7 1 50 1 50 1 100 0 0
Internalizing personality traits 6 2.2 0 0 6 100 6 100 0 0
Self-compassion/mindfulness 2 0.7 1 50 1 50 0 0 1 100
Locality (urban/rural) (6) 7 2.6 4 57.1 3 42.9 1 33.3 2 66.7
Illness-related
Severity of psychiatric symptoms 65 23 10 15.4 55 84.6 55 100 0 0
Higher distress from sub-threshold psychotic symptoms/psychiatric symptoms 2 0.7 0 0 2 100 2 100 0 0
Age of onset 26 9.6 19 73.0 7 27.0 0 0 7 100
Illness duration 32 11.8 22 68.7 10 31.3 7 70.0 3 30.0
Stage of illness 1 0.4 1 100 0 0 - - - -
Diagnosis(7) 38 14.0 20 52.6 18 47.4 NA - NA -
Insight 32 11.8 0 0 32 100 32 100 0 0
Parental insight 1 0.4 0 0 1 100 1 100 0 0
Subjective clinical severity 3 1.1 0 0 3 100 3 100 0 0
Perceived cognitive dysfunction 4 1.5 0 0 4 100 4 100 0 0
Hospitalizations 38 14.0 23 60.5 15 39.5 14 93.3 1 6.7
Treatment setting (8) 6 2.2 3 50 3 50 1 33.3 2 66.7
Involuntary hospitalizations (IH) 3 1.1 1 33.3 2 66.7 2 100 0 0
Negative emotional reactions to IH 2 0.7 0 0 2 100 2 100 0 0
Forensic patient status 3 1.1 2 66.7 1 33.3 1 100 0 0
Compulsory community treatment 1 0.4 1 100 0 0 - - - -
History of suicide attempt 6 2.2 1 16.7 5 83.3 5 100 0 100
Social anxiety 3 1.1 0 0 3 100 3 100 0 0
Comorbid post-traumatic stress disorder 2 0.7 0 0 2 100 2 100 0 0
Comorbid personality disorder 2 0.7 0 0 2 100 2 100 0 0
Cormorbid substance use disorder 3 1.1 1 33.3 2 66.7 2 100 0 0
Drug extra-pyramidal side-effects 4 1.5 0 0 4 100 4 100 0 0
Cognitive functioning 6 2.2 1 16.7 5 83.3 0 0 5 100
Social cognition 4 1.5 1 25 3 75 0 0 3 100
1273
Table 4. Continued
1274
A B C D E
Non-
J. Dubreucq et al

(n = 272) (P > 0.05) (P < 0.05) (P < 0.05) (P < 0.05)
Metacognitive abilities 7 2.6 0 0 7 100 0 0 7 100
Dysfunctional attitudes 1 0.4 0 0 1 100 1 100 0 0
Use of negative coping strategies 8 2.9 0 0 8 100 8 100 0 0
Environment-related
Country level of public stigma 6 2.2 0 0 6 100 6 100 0 0
Perceived stigma 18 6.6 0 0 18 100 18 100 0 0
Self-labelling 3 1.1 0 0 3 100 3 100 0 0
Stigma stress 4 1.5 0 0 4 100 4 100 0 0
Group value 3 1.1 0 0 3 100 0 0 3 100
Perceived legitimacy 2 0.7 0 0 2 100 2 100 0 0
Social network 11 4.0 0 0 11 100 0 0 11 100
Sense of belonging 2 0.7 0 0 2 100 0 0 2 100
Perceived social support 21 8.4 0 0 21 100 0 0 21 100
Loneliness 2 0.7 0 0 2 100 2 100 0 0
Family sense of coherence 1 0.4 0 0 1 100 0 0 1 100
Experienced and anticipated stigma 13 4.8 0 0 13 100 13 100 0 0
Expressed emotion in families 1 0.4 0 0 1 100 1 100 0 0
Associative stigma in MHP 1 0.4 0 0 1 100 1 100 0 0
Cultural factors
Attributing mental illness to supernatural causes 3 1.1 0 0 3 100 3 100 0 0
History of traditional treatment 2 0.7 0 0 2 100 2 100 0 0
Loss of face in Eastern countries 2 0.7 0 0 2 100 2 100 0 0
Psychosocial
Self-efficacy 13 4.8 0 0 13 100 0 0 13 100
Empowerment 11 4.0 0 0 11 100 0 0 11 100
Self-esteem 44 16.2 0 0 44 100 0 0 44 100
Hope 19 7.0 0 0 19 100 0 0 19 100
Depression 41 15.1 0 0 41 100 41 100 0 0
Suicide risk 15 5.5 1 6.7 14 93.3 14 100 0 0
Help-seeking/Therapeutic alliance 5 1.8 0 0 5 100 0 0 5 100
Treatment adherence 15 5.5 0 0 15 100 0 0 15 100
Subjective social status 1 0.4 0 0 1 100 0 0 1 100
Psychosocial function 27 9.9 0 0 27 100 0 0 27 100
Activity 1 0.4 0 0 1 100 0 0 1 100
Self-reported physical health 2 0.7 0 0 2 100 0 0 2 100
Capacity for intimacy/satisfaction in intimate relationships 4 1.5 0 0 4 100 0 0 4 100
Self-reported parenting experiences 1 0.4 0 0 1 0 0 0 1 100
Quality of life 41 15.1 0 0 41 100 0 0 41 100
Wellbeing 9 3.3 0 0 9 100 0 0 9 100
Satisfaction with life 8 2.9 0 0 8 100 0 0 8 100
Table 4. Continued
A B C D E
Non-
(n = 272) (P > 0.05) (P < 0.05) (P < 0.05) (P < 0.05)
“why try effect” 2 0.7 0 0 2 100 2 100 0 0
Coming out (CO)/CO assertiveness 1 0.4 1 100 0 0 - - - -
Benefits from being out 1 0.4 0 0 1 100 0 0 1 100
Stigma resistance 11 4.0 0 0 11 100 0 0 11 100
Resilience 7 2.6 0 0 7 100 0 0 7 100
Personal recovery 22 8.1 0 0 22 100 0 0 22 100
1)Columns D + E; 1 = Men.
2) Columns D + E; 1 = Employed.
3) Columns D + E; 1 = Married.
4) Columns D + E; 1 = Income earner.
5) Columns D + E; 1 = Mothers.
6) Columns D + E; 1 = Urban.
7) Columns D+ E; not applicable (heterogeneity of the samples).
8) Columns D + E; 1= Inpatients.
Table 4 presents the relationships between sociodemographic, illness-related, environment-related, cultural and psychosocial variables with self-stigma (includes 272 studies).
1275
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J. Dubreucq et al
Table 5. Longitudinal Correlates and Consequences of Self-stigma
A. B. C. D. E.
Non-
Number significant Significant Positive re- Negative
of studies relationship relationship lationship relationship
(n = 41) (P > 0.05) (P < 0.05) (P < 0.05) (P < 0.05)
Correlates of increased self-stigma at follow-up

Female sex 5 12.2 4 80 1 20 1 100 0 0
Hospitalizations 1 2.4 0 0 1 100 1 100 0 0
Duration of untreated psychosis 1 2.4 0 0 1 100 1 100 0 0
Baseline psychiatric symptoms 5 12.2 0 0 5 100 5 100 0 0
Shame, self-contempt about IH and stigma stress 2 4.9 0 0 2 100 2 100 0 0
Negative coping strategies 1 2.4 0 0 1 100 1 100 0 0
Correlates of reduced self-stigma at follow-up
Attending to recovery-oriented daycare/vocational rehabilitation/COSP 5 12.2 0 0 5 100 5 100 0 0
Work without experienced discrimination 1 2.4 0 0 1 100 1 100 0 0
Receiving no disability benefits during PR 1 2.4 0 0 1 100 1 100 0 0
Longitudinal consequences of self-stigma
Psychiatric symptoms 5 12.2 0 0 5 100 5 100 0 0
Social anxiety 1 2.4 0 0 1 100 1 100 0 0
Depression 6 14.6 0 0 6 100 6 100 0 0
Suicide risk 4 9.8 0 0 4 100 4 100 0 0
Risk of hospitalizations 1 2.4 0 0 1 100 1 100 0 0
Self-esteem 3 7.3 0 0 3 100 0 0 3 100
Treatment adherence 3 7.3 0 0 3 100 0 0 3 100
Psychosocial function 9 21.9 0 0 9 100 0 0 9 100
Quality of Life 3 7.3 0 0 3 100 0 0 3 100
Life satisfaction 1 2.4 0 0 1 100 0 0 1 100
Personal recovery 2 4.9 0 0 2 100 0 0 2 100
Note: COSP, consumer-operated service program; IH, involuntary hospitalization; PR, Psychiatric rehabilitation.
Table 5 presents the longitudinal relationships between sociodemographic, illness-related, environment-related, and psychosocial variables with self-stigma (includes 41
studies).
Table 6. Prevalence of Stigma Resistance
Area Study Country n Mean SR SD n High SR (%)
Europe SMI Grambal169 Czech Republic 184 2.52 0.57 - -

Dubreucq93 France 738 2.54 0.51 693 54.1
Weighted total 922 2.53
Schizophrenia Brohan9 Multi-site 1129 2.47 (2.29–2.7) 0.51 1129 49.2%
Vidovic126 Croatia 149 2.37 0.99 149 54%
Sibitz123 Austria 157 2.73 0.76 157 63.3%
Hofer30 Austria 52 2.94 0.53 - -
Bouvet175 France 62 2.46 0.55 - -
Vrbova176 Czech Republic 197 2.56 0.48 - -
Surmann177 Germany 80 2.35 0.58 - -
Dubreucq93 France 466 2.56 0.51 466 55.4%
Weighted total - 2292 2.51 1435 51.2%
Bipolar Disorders/MDD Brohan10 Multi-site 1182 2.81 0.98 1182 59.7%
Dubreucq93 France 117 BD 2.52 0.53 117 52.1%
27 MDD 2.58 0.53 27 59.3%
Weighted total 1326 2.77 1326 59.02%
Anxiety disorders Grambal169 Czech Republic 37 2.30 0.56 - -
Dubreucq93 France 19 2.44 0.68 19 36.8%
Borderline Personality Disorder Grambal169 Czech Republic 35 2.27 0.57 - -
Dubreucq93 France 64 2.52 0.48 64 51.6%
North America SMI Livingston37 Canada 71 2.07 0.38 - -
Livingston43 Canada 94 2.10 0.50 94 15.9%
Ritsher-Boyd112 USA - - - 82 29%
Weighted total - 165 2.08 176 22%
Bipolar Disorders Howland42 USA 115 3.06 0.46 - -
South America Schizophrenia Caqueo-Uritzar34 Multi-site 253 2.4 0.61 - –
South Asia Schizophrenia Singh198 India 100 2.3 0.70 100 45%
Pal199 India 32 2.84 0.50 -
Weighted total - 132 2.43 100 45%
Bipolar Disorders Pal199 India 59 2.43 0.42 - -
Grover200 India 185 2.21 0.51 - -
Weighted total - 244 2.26 - -
South-East Asia SMI Ran127 China 453 2.49 0.42 - -
Lau221 Singapore 280 2.87 0.47 280 82.9%
Weighted total 733 2.63
Schizophrenia Li139 China 384 2.28 0.45 - -
Hofer30 Japan 60 2.35 0.46 - -
Ran127 China 232 2.50 0.36 - -
Weighted total - 676 2.36 - -
Middle East SMI Ghanean208 Iran 138 2.46 0.39 - -
Schizophrenia Sarisoy41 Turkey 109 2.56 0.62 - -
Çapar212 Turkey 250 2.41 0.35 - -
Olçun213 Turkey 76 2.60 0.60 - -
Karakas222 Turkey 60 2.62 0.63 - -
Yilmaz214 Turkey 63 2.66 0.43 - -
Weighted total score - 558 2.51 - -
Bipolar Disorders Sarisoy41 Turkey 118 2.38 0.54 - -
Sadighi216 Iran 126 2.76 0.98 126 57.49%
1277
J. Dubreucq et al
however, associated with improvements in QoL105 during
High SR (%)
Note: MDD, Major Depressive Disorder; SMI, Severe Mental Illness. Mean stigma resistance refers to ISMI stigma resistance subscale mean score. High stigma resistance re-
psychiatric rehabilitation.
58.34%
72.7%
49.4%
-
-
-
Self-stigma and Stigma Resistance
Thirty-one studies (11.9%) reported data on stigma re-
sistance frequency in SMI. The results are shown in
fers to the proportion of patients with ISMI stigma resistance subscale > 2.5. Bold faces represents the total sample and the weighted means and proportions.
667
256
411
table 6. Stigma resistance was higher in mood disorders
n
-
-
-
(59.7%10) than in schizophrenia (53.1%; n = 5). Stigma
resistance in schizophrenia varied within Europe (from
49.2%9 to 63%123 and Africa (from 49.4% in Ethiopia124
0.40
0.53
SD
-
to 72.7% in Nigeria125). Stigma resistance was negatively
correlated with self-stigma in Austria,30,123 Croatia,126
Nigeria,125 and South Africa.62 In some countries, self-
stigma and stigma resistance were both high (USA,42
Mean SR
Turkey, Ethiopia,124 India, Bolivia,34 Peru,34 Chile,34

and China127) and in Canada these were both low.36,37
2.55
2.41
2.90
2.53
2.79
2.52
2.62
Metacognitive abilities,128–130 social network,123,131 social

power,132 self-compassion,131 psychological flexibility,131
fear of negative evaluation,128 perceived stigma,60,114 neg-
ative symptoms,130 and coping strategies129,133 were associ-
ated with high stigma resistance.
246
422
142
564
256
411
667
n
Discussion
South Africa
Research on self-stigma in SMI has considerably pro-

Ethiopia
Ethiopia
gressed over the past decade (244 articles since 2010

Country
Nigeria
and 28 studies published prior to this).7 Self-stigma was

present in all geographical areas with higher frequency in
South-East Asia and the Middle East for SMI (>39%).
Self-stigma in SMI was higher in the Middle East, South
Asia, South-East Asia, and Africa than in Europe or
North America. Schizophrenia was associated with high
Mosanya125
Sorsdahl62
self-stigma in all geographical areas (32.6%–44.2%). Self-

Girma53
Bifftu124
stigma in schizophrenia was higher in the Middle East,

Study
South-East Asia, South Asia, and South America than in

-
Europe. Self-stigma differed according to the geograph-

ical area in mood disorders (higher self-stigma in South
Asia and South-East Asia in comparison with Europe,
North America, or the Middle East). Variations in pat-
terns of stigma according to the cultural area might ex-
plain these differences. The greater public stigma relating
to SMI in Eastern countries compared with Western
Weighted total score
countries could explain the higher levels of self-stigma in

Weighted total
Weighted total
Schizophrenia
South Asia and South-East Asia.134 Other potential fac-

tors contributing to higher self-stigma include feelings
Area
of shame about not meeting the social expectations of

SMI
“what matters most” in one’s social group,14,16 moral or

supernatural causal attributions of mental illness, and so-
Table 6. Continued
cial concerns about the spillover effects disclosing mental

illness might have on the social and economic status of
family members.53,55,134 The frequency of self-stigma is
consistently high across the world. This concurs with
several cross-national studies on perceived, experienced,
Africa
or anticipated stigma.3,135–137 Lower rates of experienced
1278
stigma, but similar levels of self-stigma for people with The association between self-stigma with treatment
schizophrenia were reported in China and India com- setting varies (50% significance). Two studies reported
pared with Western countries.16,138,139 Cultural factors (eg, higher self-stigma in outpatients compared with in-
concerns about disclosure spillover on family members) patients152,153 and one the opposite.83 Loneliness, low so-
leading to higher self-stigma and social withdrawal might cial support, perceived stigma, experienced stigma, and
explain these variations.14,16,138,139 Most of the instruments anticipated stigma might contribute to higher self-stigma
used for assessing self-stigma in non-Western countries in outpatients.152,153 Participating in community activities,
were adapted from scales developed in Europe or North good social support, and attending psychiatric rehabili-
America and did not include culture-specific items. These tation services or consumer-operated service programs
scales might not reflect all the culture-specific forms of protect against self-stigma.9,62,105,108 Stigma stress, nega-
stigma.55,140 Anti-stigma campaigns and self-stigma re- tive emotional reactions to involuntary hospitalization,
duction interventions should take into consideration cul- and the use of avoidant coping strategies after discharge
tural factors (eg, cost/benefits of strategic disclosure in a contribute to higher self-stigma.57,58,102 Improved inpa-
given cultural context35,54,141). tient care (ie, the implementation of recovery-oriented
Cultural and socio-ideological factors might ac- practices and interventions targeting stigma stress, ther-
count for the large country-related variations that were apeutic alliance and coping strategies) might result in
found within geographical areas. Higher public stigma better patient outcomes after discharge, although this re-
was found in Eastern/Southern Europe compared with mains to be investigated.
Western Europe.142–144 Compared with Western Europe The development of recovery-oriented practices in
or Canada, higher levels of self-reported sociopolit- mental health facilities should be encouraged as it could
ical conservatism were found in Eastern Europe and the reduce perceived stigma, stigma stress,57–59 and negative
USA.145,146 Gonzales147 and De Luca148 found that self- emotional reactions to involuntary admissions.57–59 Peer-
reported political conservatism and right-wing authori- supported self-management interventions, Joint Crisis
tarianism were associated with increased public stigma. Plans, “No Force First” policies, and selective disclosure
Cultural factors (eg, the endorsement of traditional cul- programs could improve self-stigma through reduced
tural values, higher in China than in Taiwan or South stigma stress and perceived coercion.151,154–156 Recovery-
Korea149) might contribute to the differences observed be- oriented training programs for mental health profes-
tween Guangzhou and Hong Kong35 or between Taiwan sionals improve personal recovery in people with SMI.157
and South Korea.39,40 These variations could be related They may also improve mental health professionals’ job
to sample characteristics (eg, higher reliance on family satisfaction, burnout, and associative stigma of mental
support in Guangzhou compared with Hong Kong; 35 illness.15,63 Their effectiveness in reducing self-stigma in
higher proportion of patients with BD in Korea than in patients should be investigated.
Taiwan39,40). Given the potential relationships with stigma stress,50
Sociodemographic and illness-related correlates yielded duration of untreated psychosis,97 distress from sub-
mixed results in line with previous reviews.7,8 Self-stigma threshold psychotic symptoms,47 and transition to
was high in BPD but this is based on a small number of psychosis,50 the effects of recovery-oriented early inter-
studies with small sample sizes. Self-stigma was equally ventions on self-stigma and its consequences should be
severe in the at-risk stages as in psychosis.111 Further re- further investigated. Strategic disclosure programs result
search is needed to confirm this result. Self-stigma was in people making empowered decisions about whether to
closely associated with perceived and experienced stigma. disclose a diagnosis of SMI or not. They result in im-
These concepts are distinct and should be better differen- proved stigma stress and self-stigma in adolescents with
tiated between, as stereotype awareness and self-labeling SMI151 and should be integrated into recovery-oriented
do not necessarily imply stereotype agreement, self- early intervention services.
application, and increased self-stigma.91,150 Self-support As expected,7,8 self-stigma was negatively associated
groups and recovery-oriented services promoting posi- with recovery-related outcomes and positively associated
tive group identification60,106 should be further developed with depression and suicidal ideation. Cognitive impair-
to prevent or reduce self-stigma. Reducing self-stigma ments, dysfunctional attitudes, and avoidant coping strat-
implies targeting the explicitly negative views about the egies were positively associated with self-stigma. Insight
self that relate to being diagnosed with SMI. Making an into illness was the most significant moderator of intern-
empowered decision about disclosing an SMI diagnosis alized stigma. Perceived cognitive dysfunction, perceived
might be effective for adolescents or people in the early and experienced stigma all had indirect effects on clin-
stages of self-stigma.91,151 People in the late stages of self- ical and functional outcomes via self-stigma. Baseline
stigma may need to take part in group interventions com- self-stigma was associated with poorer recovery-related
bining psychoeducation and cognitive restructuring.21,57 outcomes and less benefit from vocational rehabilitation
Interventions should be proposed to each individual ac- at follow-up.8,119 Reduction in self-stigma was associated
cording to his/her personal needs and level of self-stigma. with improved depression, suicidality, attitudes towards
1279
J. Dubreucq et al
medication, self-esteem, QoL, and social function at more limited focus (eg, on the impact of self-stigma on
follow-up. recovery-related outcomes) could be conducted to ex-
Improved treatment (ie, recovery-oriented practices and plore the present findings in more detail.
nonspecific interventions targeting therapeutic alliance,
dysfunctional attitudes, self-esteem, or coping strategies) Conclusions
could indirectly reduce self-stigma.158–160 Recovery-
oriented psychoeducation improves treatment adherence In short, self-stigma is a severe problem in all SMI con-
and reduces the risk of hospitalization.161 Improved ther- ditions (including the at-risk stages) and all geographical
apeutic alliance is associated with better recovery-related areas and is associated with poor clinical and functional
outcomes after attending to early interventions services.158 outcomes. Levels of public, perceived, and experienced
Other interventions such as cognitive behavioral therapy, stigma (including from mental health providers) are sig-
cognitive remediation, or social skills training might re- nificant predictors of self-stigma, pleading for the rein-
duce self-stigma through improved symptoms, dysfunc- forcement of anti-stigma campaigns and the development
tional attitudes, and functioning.22,159,160,162 Given the of recovery-oriented practices in mental health settings.
potential relationship between expressed emotion in the The respective associations between the duration of un-
families of people with SMI and self-stigma and recovery- treated psychosis, self-stigma, and transition to psychosis
related outcomes,64,65 family psychoeducation could be ef- support the development of recovery-oriented early in-
fective for self-stigma.163 Family psychoeducation should tervention programs. Psychiatric rehabilitation could be
be recovery-oriented and address both public stigma and an effective means of reducing self-stigma and should
self-stigma.164–167 The relationship between self-stigma in therefore be further developed in public policies.
people with SMI and in their relatives is still unclear and
should be further investigated.168
Stigma resistance and self-stigma were negatively asso- Supplementary Material
ciated with each other6 but with different patterns. Self-
Supplementary material is available at https://academic.
stigma and stigma resistance are distinct constructs and
oup.com/schizophreniabulletin/.
should be measured using more specific scales.6
Limitations Acknowledgments
There are some limitations to this review due to the het- The authors would like to thank Mrs Kim Barrett for
erogeneity in the definition of SMI and in the samples, proofreading the manuscript. They are also grateful to
settings, methods, scales, and reported outcomes. Few the reviewers of a previous version of the manuscript for
articles reported longitudinal outcomes with a limited their helpful comments.
number of studies conducted in psychiatric rehabilitation Author contribution: The two authors had full access to
settings. This review excluded studies where self-stigma the data in the study and take the responsibility for the
was not the main focus, which means that stigma in all its integrity of the data and the accuracy of the data anal-
forms (ie, perceived, experienced or anticipated stigma, ysis. Dr Julien Dubreucq drafted the article. Dr Julien
and self-stigma) could actually have more wide-ranging Dubreucq and Prof Nicolas Franck carried out the liter-
effects on people with SMI. However, by focusing on ature review. M. Julien Plasse did the statistical analysis.
self-stigma, this review provides a more accurate under- Prof Nicolas Franck critically revised the article. Both
standing of its effects on people with SMI. The hetero- authors were involved in the collection and analysis of
geneity of the samples, methods, scales, and reported the data. Both authors contributed to and approved the
outcomes in the included articles limited the possibil- final manuscript.
ities for extracting comparable data. The large number Conflicts of interests: none.
of studies included in this review and the range of coun-
tries represented is however a considerable strength. The
under-reporting of negative or nonsignificant results due Funding
to publication bias and the exclusion of unpublished
studies from this review might have limited the accuracy This research did not receive any specific grants
of the synthesis. The present systematic review does not from funding agencies in the public, commercial, or
include a meta-analysis. This decision was made due to not-for-profit sectors.
the large number of studies and the heterogeneity of
the samples, methods, scales, and reported outcomes.
Statistical analyses were used to compare self-stigma fre- References
quency in different geographical areas (the second objec- 1. Link BG, Phelan JC. Conceptualizing stigma. Annu Rev
tive of the present study). Future meta-analyses with a Sociol. 2001;27:363–385.
1280
2. Corrigan PW, Larson JE, Rüsch N. Self-stigma and the “why 19. Rüsch N, Hölzer A, Hermann C, et al. Self-stigma in women
try” effect: impact on life goals and evidence-based practices. with borderline personality disorder and women with social
World Psychiatry. 2009;8(2):75–81. phobia. J Nerv Ment Dis. 2006;194(10):766–773.
3. Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M; 20. Gunderson JG, Herpertz SC, Skodol AE, Torgersen S,
INDIGO Study Group. Global pattern of experienced and Zanarini MC. Borderline personality disorder. Nat Rev Dis
anticipated discrimination against people with schizophrenia: Primers. 2018;4:18029.
a cross-sectional survey. Lancet. 2009;373(9661):408–415. 21. Yanos PT, Lucksted A, Drapalski AL, Roe D,
4. Yanos PT, Roe D, Markus K, Lysaker PH. Pathways be- Lysaker P. Interventions targeting mental health self-
tween internalized stigma and outcomes related to re- stigma: a review and comparison. Psychiatr Rehabil J.
covery in schizophrenia spectrum disorders. Psychiatr Serv. 2015;38(2):171–178.
2008;59(12):1437–1442. 22. Franck N, Bon L, Dekerle M, et al. Satisfaction and needs
5. Thoits PA. Resisting the stigma of mental illness. Soc Psychol in serious mental illness and autism spectrum disorder: the
Q. 2011;74(1):6–28. REHABase psychosocial rehabilitation project. Psychiatr
6. Firmin RL, Luther L, Lysaker PH, Minor KS, Salyers MP. Serv. 2019;70(4):316–323.
Stigma resistance is positively associated with psychiatric 23. Moritz S, Gawęda Ł, Heinz A, Gallinat J. Four reasons why
and psychosocial outcomes: a meta-analysis. Schizophr Res. early detection centers for psychosis should be renamed
2016;175(1–3):118–128. and their treatment targets reconsidered: we should not
7. Livingston JD, Boyd JE. Correlates and consequences of catastrophize a future we can neither reliably predict nor
internalized stigma for people living with mental illness: change. Psychol Med. 2019;49(13):2134–2140.
a systematic review and meta-analysis. Soc Sci Med. 24. Yang LH, Lo G, WonPat-Borja AJ, Singla DR, Link BG,
2010;71(12):2150–2161. Phillips MR. Effects of labeling and interpersonal contact
8. Gerlinger G, Hauser M, De Hert M, Lacluyse K, Wampers M, upon attitudes towards schizophrenia: implications for re-
Correll CU. Personal stigma in schizophrenia spectrum dis- ducing mental illness stigma in urban China. Soc Psychiatry
orders: a systematic review of prevalence rates, correlates, im- Psychiatr Epidemiol. 2012;47(9):1459–1473.
pact and interventions. World Psychiatry. 2013;12(2):155–164. 25. Moher D, Shamseer L, Clarke M, et al. Preferred reporting
9. Brohan E, Elgie R, Sartorius N, Thornicroft G; GAMIAN- items for systematic review and meta-analysis protocols
Europe Study Group. Self-stigma, empowerment and per- (PRISMA-P) 2015 statement. Syst Rev. 2015;4:1.
ceived discrimination among people with schizophrenia in 14 26. Wood L, Byrne R, Varese F, Morrison AP. Psychosocial inter-
European countries: the GAMIAN-Europe study. Schizophr ventions for internalised stigma in people with a schizophrenia-
Res. 2010;122(1–3):232–238. spectrum diagnosis: a systematic narrative synthesis and
10. Brohan E, Gauci D, Sartorius N, Thornicroft G; GAMIAN- meta-analysis. Schizophr Res. 2016;176(2–3):291–303.
Europe Study Group. Self-stigma, empowerment and per- 27. Ross LE, Grigoriadis S, Mamisashvili L, et al. Quality assess-
ceived discrimination among people with bipolar disorder or ment of observational studies in psychiatry: an example from
depression in 13 European countries: the GAMIAN-Europe perinatal psychiatric research. Int J Methods Psychiatr Res.
study. J Affect Disord. 2011;129(1–3):56–63. 2011;20(4):224–234.
11. Ellison N, Mason O, Scior K. Bipolar disorder and stigma: 28. Kohrt BA, Rasmussen A, Kaiser BN, et al. Cultural concepts
a systematic review of the literature. J Affect Disord. of distress and psychiatric disorders: literature review and re-
2013;151(3):805–820. search recommendations for global mental health epidemi-
12. Hawke LD, Parikh SV, Michalak EE. Stigma and bi- ology. Int J Epidemiol. 2014;43(2):365–406.
polar disorder: a review of the literature. J Affect Disord. 29. Ritsher JB, Otilingam PG, Grajales M. Internalized stigma
2013;150(2):181–191. of mental illness: psychometric properties of a new measure.
13. West ML, Yanos PT, Smith SM, Roe D, Lysaker PH. Psychiatry Res. 2003;121(1):31–49.
Prevalence of internalized stigma among persons with severe 30. Hofer A, Mizuno Y, Frajo-Apor B, et al. Resilience, internal-
mental illness. Stigma Res Action. 2011;1(1):3–10. ized stigma, self-esteem, and hopelessness among people with
14. Yang LH, Chen FP, Sia KJ, et al. “What matters most:” a schizophrenia: cultural comparison in Austria and Japan.
cultural mechanism moderating structural vulnerability and Schizophr Res. 2016;171(1–3):86–91.
moral experience of mental illness stigma. Soc Sci Med. 31. Mileva VR, Vázquez GH, Milev R. Effects, experiences,
2014;103:84–93. and impact of stigma on patients with bipolar disorder.
15. Yanos PT, DeLuca JS, Salyers MP, Fischer MW, Song J, Neuropsychiatr Dis Treat. 2013;9:31–40.
Caro J. Cross-sectional and prospective correlates of associa- 32. Corrigan P, Watson A, Barr L. The self-stigma of mental
tive stigma among mental health service providers. Psychiatr illness: implications for self-esteem and self-efficacy. J Soc
Rehabil J. 2020;43(2):85–90. Clin Psychol. 2006;25:875e884.
16. Koschorke M, Padmavati R, Kumar S, et al. Experiences of 33. Krajewski C, Burazeri G, Brand H. Self-stigma, perceived
stigma and discrimination of people with schizophrenia in discrimination and empowerment among people with a
India. Soc Sci Med. 2014;123:149–159. mental illness in six countries: Pan European stigma study.
17. Yang LH, Wonpat-Borja AJ, Opler MG, Corcoran CM. Psychiatry Res. 2013;210(3):1136–1146.
Potential stigma associated with inclusion of the psych- 34. Caqueo-Urízar A, Boyer L, Urzúa A, Williams DR. Self-
osis risk syndrome in the DSM-V: an empirical question. stigma in patients with schizophrenia: a multicentric study
Schizophr Res. 2010;120(1–3):42–48. from three Latin-America countries. Soc Psychiatry Psychiatr
18. Yang LH, Anglin DM, Wonpat-Borja AJ, Opler MG, Epidemiol. 2019;54(8):905–909.
Greenspoon M, Corcoran CM. Public stigma associated with 35. Young DK, Ng PY. The prevalence and predictors of self-
psychosis risk syndrome in a college population: implications stigma of individuals with mental health illness in two
for peer intervention. Psychiatr Serv. 2013;64(3):284–288. Chinese cities. Int J Soc Psychiatry. 2016;62(2):176–185.
1281
J. Dubreucq et al
36. Livingston JD, Rossiter KR, Verdun-Jones SN. ‘Forensic’ label- 53. Girma E, Tesfaye M, Froeschl G, Möller-Leimkühler AM,
ling: an empirical assessment of its effects on self-stigma for people Dehning S, Müller N. Facility based cross-sectional study
with severe mental illness. Psychiatry Res. 2011;188(1):115–122. of self-stigma among people with mental illness: towards
37. Livingston J. Self-stigma and quality of life among people patient empowerment approach. Int J Ment Health Syst.
with mental illness who receive compulsory community treat- 2013;7(1):21.
ment services. J Community Psychol. 2012;40:699–714. 54. Makanjuola V, Esan Y, Oladeji B, et al. Explanatory model
38. Harris JI, Farchmin L, Stull L, Boyd J, Schumacher M, of psychosis: impact on perception of self-stigma by patients
Drapalski AL. Prediction of changes in self-stigma among in three sub-Saharan African cities. Soc Psychiatry Psychiatr
veterans participating in partial psychiatric hospitalization: Epidemiol. 2016;51(12):1645–1654.
the role of disability status and military cohort. Psychiatr 55. Ibrahim AW, Mukhtar YM, Sadique PK, et al. A facility-
Rehabil J. 2015;38(2):179–185. based assessment of internalized stigma among patients with
39. Kim WJ, Song YJ, Ryu HS, et al. Internalized stigma and severe mental illnesses in Maiduguri, North-Eastern Nigeria.
its psychosocial correlates in Korean patients with serious Int Neuropsychiatr Dis J. 2016;6(1):1–11.
mental illness. Psychiatry Res. 2015;225(3):433–439. 56. Chen ES, Chang WC, Hui CL, Chan SK, Lee EH, Chen EY.
40. Kao YC, Lien YJ, Chang HA, Wang SC, Tzeng NS, Loh CH. Self-stigma and affiliate stigma in first-episode psych-
Evidence for the indirect effects of perceived public stigma osis patients and their caregivers. Soc Psychiatry Psychiatr
on psychosocial outcomes: the mediating role of self-stigma. Epidemiol. 2016;51(9):1225–1231.
Psychiatry Res. 2016;240:187–195. 57. Xu Z, Lay B, Oexle N, Drack T, et al. Involuntary psychiatric
41. Sarısoy G, Kaçar ÖF, Pazvantoğlu O, et al. Internalized stigma hospitalization, stigma stress and recovery: a 2-year study.
and intimate relations in bipolar and schizophrenic patients: Epidemiol Psychiatr Sci. 2018a;31:1–8.
a comparative study. Compr Psychiatry. 2013;54(6):665–672. 58. Rüsch N, Müller M, Lay B, et al. Emotional reactions to
42. Howland M, Levin J, Blixen C, Tatsuoka C, Sajatovic M. involuntary psychiatric hospitalization and stigma-related
Mixed-methods analysis of internalized stigma correlates stress among people with mental illness. Eur Arch Psychiatry
in poorly adherent individuals with bipolar disorder. Compr Clin Neurosci. 2014;264(1):35–43.
Psychiatry. 2016;70:174–180. 59. Chang CC, Wu TH, Chen CY, Lin CY. Comparing self-stigma
43. Livingston J, Patel N, Bryson S, et al. Stigma associated with between people with different mental disorders in Taiwan. J
mental illness among Asian men in Vancouver, Canada. Int J Nerv Ment Dis. 2016;204(7):547–553.
Soc Psychiatry. 2018;64(7):679–689. 60. Rüsch N, Corrigan PW, Wassel A, et al. Ingroup perception
44. Lacey M, Paolini S, Hanlon MC, Melville J, Galletly C, and responses to stigma among persons with mental illness.
Campbell LE. Parents with serious mental illness: differences Acta Psychiatr Scand. 2009;120(4):320–328.
in internalised and externalised mental illness stigma and 61. Hsiao CY, Lu HL, Tsai YF. Effect of family sense of coher-
gender stigma between mothers and fathers. Psychiatry Res. ence on internalized stigma and health-related quality of life
2015;225(3):723–733. among individuals with schizophrenia. Int J Ment Health
45. Bradstreet S, Dodd A, Jones S. Internalised stigma in mental Nurs. 2018;27(1):138–146.
health: an investigation of the role of attachment style. 62. Sorsdahl KR, Kakuma R, Wilson Z, Stein DJ. The intern-
Psychiatry Res. 2018;270:1001–1009. alized stigma experienced by members of a mental health
46. Døssing M, Nilsson KK, Svejstrup SR, Sørensen VV, advocacy group in South Africa. Int J Soc Psychiatry.
Straarup KN, Hansen TB. Low self-compassion in patients 2012;58(1):55–61.
with bipolar disorder. Compr Psychiatry. 2015;60:53–58. 63. Verhaeghe M, Bracke P. Associative stigma among mental
47. Denenny D, Thompson E, Pitts SC, Dixon LB, health professionals: implications for professional and service
Schiffman J. Subthreshold psychotic symptom distress, user well-being. J Health Soc Behav. 2012;53(1):17–32.
self-stigma, and peer social support among college stu- 64. Chan KKS, Lam CB. The impact of familial expressed
dents with mental health concerns. Psychiatr Rehabil J. emotion on clinical and personal recovery among pa-
2015;38(2):164–170. tients with psychiatric disorders: the mediating roles of
48. Pyle M, Morrison AP. Internalised stereotypes across self-stigma content and process. Am J Orthopsychiatry.
ultra-high risk of psychosis and psychosis populations. 2018;88(6):626–635.
Psychosis. 2017;9:1–9. 65. Chan RCH, Mak WWS, Lam MYY. Self-stigma and em-
49. Larsen EM, Herrera S, Bilgrami ZR, et al. Self-stigma related powerment as mediating mechanisms between ingroup per-
feelings of shame and facial fear recognition in individuals at ceptions and recovery among people with mental illness.
clinical high risk for psychosis: a brief report. Schizophr Res. Stigma and Health. 2018a;3(3):283–293.
2019;208:483–485. 66. Gaziel M, Hasson-Ohayon I, Morag-Yaffe M, Schapir L,
50. Rüsch N, Heekeren K, Theodoridou A, et al. Stigma as a stressor Zalsman G, Shoval G. Insight and satisfaction with life
and transition to schizophrenia after one year among young among adolescents with mental disorders: assessing associ-
people at risk of psychosis. Schizophr Res. 2015;166(1–3):43–48. ations with self-stigma and parental insight. Eur Psychiatry.
51. Evans-Lacko S, Brohan E, Mojtabai R, Thornicroft G. 2015;30(2):329–333.
Association between public views of mental illness and self- 67. Mak WW, Wu CF. Cognitive insight and causal attribution
stigma among individuals with mental illness in 14 European in the development of self-stigma among individuals with
countries. Psychol Med. 2012;42(8):1741–1752. schizophrenia. Psychiatr Serv. 2006;57(12):1800–1802.
52. Wang K, Link BG, Corrigan PW, Davidson L, Flanagan E. 68. Park SG, Bennett ME, Couture SM, Blanchard JJ.
Perceived provider stigma as a predictor of mental health Internalized stigma in schizophrenia: relations with dysfunc-
service users’ internalized stigma and disempowerment. tional attitudes, symptoms, and quality of life. Psychiatry
Psychiatry Res. 2018;259:526–531. Res. 2013;205(1–2):43–47.
1282
69. West ML, Mulay AL, DeLuca JS, et al. Forensic psychi- 86. Stip E, Caron J, Tousignant M, Lecomte Y. Suicidal ideation
atric experiences, stigma, and self-concept: a mixed-methods and schizophrenia: contribution of appraisal, stigmatization,
study. J Forens Psychiatry Psychol. 2018;29:574–596. and cognition. Can J Psychiatry. 2017;62(10):726–734.
70. Lysaker PH, Vohs J, Hasson-Ohayon I, Kukla M, Wierwille J, 87. Oexle N, Waldmann T, Staiger T, Xu Z, Rüsch N. Mental
Dimaggio G. Depression and insight in schizophrenia: com- illness stigma and suicidality: the role of public and indi-
parisons of levels of deficits in social cognition and metacog- vidual stigma. Epidemiol Psychiatr Sci. 2018;27(2):169–175.
nition and internalized stigma across three profiles. Schizophr 88. Shin YJ, Joo YH, Kim JH. Self-perceived cognitive deficits
Res. 2013;148(1–3):18–23. and their relationship with internalized stigma and quality of
71. Chan RCH, Mak WWS. Common sense model of mental life in patients with schizophrenia. Neuropsychiatr Dis Treat.
illness: understanding the impact of cognitive and emotional 2016;12:1411–1417.
representations of mental illness on recovery through the me- 89. Corrigan PW, Bink AB, Schmidt A, Jones N, Rüsch N. What
diation of self-stigma. Psychiatry Res. 2016;246:16–24. is the impact of self-stigma? Loss of self-respect and the “why
72. Chiu MY, Davidson L, Lo WT, Yiu MG, Ho WW. Modeling try” effect. J Ment Health. 2016;25(1):10–15.
self-agency among people with schizophrenia: empirical 90. Cunningham KC, Lucksted A. Social cognition, internalized
evidence for consumer-based recovery. Psychopathology. stigma, and recovery orientation among adults with serious
2013;46(6):413–420. mental illness. Psychiatr Rehabil J. 2017;40(4):409–411.
73. Kvrgic S, Cavelti M, Beck EM, Rüsch N, Vauth R. Therapeutic 91. Corrigan PW, Michaels PJ, Powell K, et al. Who comes out
alliance in schizophrenia: the role of recovery orientation, with their mental illness and how does it help? J Nerv Ment
self-stigma, and insight. Psychiatry Res. 2013;209(1):15–20. Dis. 2016;204(3):163–168.
74. Hamann J, Bühner M, Rüsch N. Self-stigma and consumer 92. Galderisi S, Rucci P, Kirkpatrick B, et al. Interplay among
participation in shared decision making in mental health psychopathologic variables, personal resources, context-
services. Psychiatr Serv. 2017;68(8):783–788. related factors, and real-life functioning in individuals
75. Cavelti M, Kvrgic S, Beck EM, Rüsch N, Vauth R. Self- with schizophrenia: a network analysis. JAMA Psychiatry.
stigma and its relationship with insight, demoralization, and 2018;75(4):396–404.
clinical outcome among people with schizophrenia spectrum 93. Dubreucq J, Plasse J, Gabayet F, et al. Self-stigma in serious
disorders. Compr Psychiatry. 2012;53(5):468–479. mental illness and autism spectrum disorder: results from the
76. Lien YJ, Chang HA, Kao YC, Tzeng NS, Lu CW, REHABase national psychiatric rehabilitation cohort. Eur
Loh CH. Insight, self-stigma and psychosocial outcomes in Psychiatry. 2020;63(1):e13.
Schizophrenia: a structural equation modelling approach. 94. Yildirim T, Kavak Budak F. The relationship between intern-
Epidemiol Psychiatr Sci. 2018;27(2):176–185. alized stigma and loneliness in patients with schizophrenia.
77. Lysaker PH, Roe D, Yanos PT. Toward understanding the Perspect Psychiatr Care. 2020;56(1):168–174. doi: 10.1111/
insight paradox: internalized stigma moderates the asso- ppc.12399.
ciation between insight and social functioning, hope, and 95. Prasko J, Ociskova M, Grambal A, et al. Personality fea-
self-esteem among people with schizophrenia spectrum dis- tures, dissociation, self-stigma, hope, and the complex
orders. Schizophr Bull. 2007;33(1):192–199. treatment of depressive disorder. Neuropsychiatr Dis Treat.
78. Valiente C, Provencio M, Espinosa R, Duque A, Everts F. 2016;12:2539–2552.
Insight in paranoia: the role of experiential avoidance and 96. Oexle N, Rüsch N, Viering S, et al. Self-stigma and suicidality:
internalized stigma. Schizophr Res. 2015;164(1–3):214–220. a longitudinal study. Eur Arch Psychiatry Clin Neurosci.
79. Konsztowicz S, Lepage M. The role of illness engulfment 2017;267(4):359–361.
in the association between insight and depressive symptom- 97. Ho RWH, Chang WC, Kwong VWY, et al. Prediction of
atology in schizophrenia. J Psychiatr Res. 2019;111:1–7. self-stigma in early psychosis: 3-Year follow-up of the
80. MacDougall AG, Vandermeer MR, Norman RM. Negative randomized-controlled trial on extended early intervention.
future self as a mediator in the relationship between in- Schizophr Res. 2018;195:463–468.
sight and depression in psychotic disorders. Schizophr Res. 98. Ben-Zeev D, Frounfelker R, Morris SB, Corrigan PW.
2015;165(1):66–69. Predictors of self-stigma in schizophrenia: new insights using
81. Aukst-Margetić B, Jakšić N, Boričević Maršanić V, mobile technologies. J Dual Diagn. 2012;8(4):305–314.
Jakovljević M. Harm avoidance moderates the relationship 99. Xu Z, Müller M, Lay B, et al. Involuntary hospitaliza-
between internalized stigma and depressive symptoms in pa- tion, stigma stress and suicidality: a longitudinal study. Soc
tients with schizophrenia. Psychiatry Res. 2014;219(1):92–94. Psychiatry Psychiatr Epidemiol. 2018;53(3):309–312.
82. Espinosa R, Valiente C, Rigabert A, Song H. Recovery style 100. Lysaker PH, Davis LW, Warman DM, Strasburger A,
and stigma in psychosis: the healing power of integrating. Beattie N. Stigma, social function and symptoms in schizo-
Cogn Neuropsychiatry. 2016;21(2):146–155. phrenia and schizoaffective disorder: associations across
83. Świtaj P, Grygiel P, Anczewska M, Wciórka J. Loneliness me- 6 months. Psychiatry Res. 2007;149(1–3):89–95.
diates the relationship between internalised stigma and de- 101. Lysaker PH, Roe D, Ringer J, Gilmore EM, Yanos PT. Change
pression among patients with psychotic disorders. Int J Soc in self-stigma among persons with schizophrenia enrolled in re-
Psychiatry. 2014;60(8):733–740. habilitation: associations with self-esteem and positive and emo-
84. Rossi A, Galderisi S, Rocca P, et al. Personal resources and tional discomfort symptoms. Psychol Serv. 2012;9(3):240–247.
depression in schizophrenia: the role of self-esteem, resilience 102. Moses T. Coping strategies and self-stigma among adoles-
and internalized stigma. Psychiatry Res. 2017;256:359–364. cents discharged from psychiatric hospitalization: a 6-month
85. Mashiach-Eizenberg M, Hasson-Ohayon I, Yanos PT, follow-up study. Int J Soc Psychiatry. 2015;61(2):188–197.
Lysaker PH, Roe D. Internalized stigma and quality of life 103. Lysaker PH, Tunze C, Yanos PT, Roe D, Ringer J, Rand K.
among persons with severe mental illness: the mediating roles Relationships between stereotyped beliefs about mental illness,
of self-esteem and hope. Psychiatry Res. 2013;208(1):15–20. discrimination experiences, and distressed mood over 1 year
1283
J. Dubreucq et al
among persons with schizophrenia enrolled in rehabilitation. 120. Xu Z, Mayer B, Müller M, et al. Stigma and suicidal idea-
Soc Psychiatry Psychiatr Epidemiol. 2012;47(6):849–855. tion among young people at risk of psychosis after one year.
104. Lagger N, Amering M, Sibitz I, Gmeiner A, Schrank B. Psychiatry Res. 2016;243:219–224.
Stability and mutual prospective relationships of stereo- 121. Xu Z, Müller M, Heekeren K, et al. Self-labelling and stigma
typed beliefs about mental illness, hope and depressive symp- as predictors of attitudes towards help-seeking among people
toms among people with schizophrenia spectrum disorders. at risk of psychosis: 1-year follow-up. Eur Arch Psychiatry
Psychiatry Res. 2018;268:484–489. Clin Neurosci. 2016;266(1):79–82.
105. Pearl RL, Forgeard MJC, Rifkin L, et al. Internalized stigma 122. Yanos PT, West ML, Gonzales L, Smith SM, Roe D,
of mental illness: changes and associations with treatment Lysaker PH. Change in internalized stigma and social func-
outcomes. Stigma Health. 2017;2:2–15. tioning among persons diagnosed with severe mental illness.
106. Sibitz I, Provaznikova K, Lipp M, Lakeman R, Amering M. Psychiatry Res. 2012;200(2–3):1032–1034.
The impact of recovery-oriented day clinic treatment on 123. Sibitz I, Unger A, Woppmann A, Zidek T, Amering M.
internalized stigma: preliminary report. Psychiatry Res. Stigma resistance in patients with schizophrenia. Schizophr
2013;209(3):326–332. Bull. 2011;37(2):316–323.
107. Rüsch N, Nordt C, Kawohl W, et al. Work-related dis- 124. Bifftu BB, Dachew BA, Tiruneh BT. Stigma resistance among
crimination and change in self-stigma among people with people with schizophrenia at Amanuel Mental Specialized
mental illness during supported employment. Psychiatr Serv. Hospital Addis Ababa, Ethiopia: a cross-sectional institution
2014;65(12):1496–1498. based study. BMC Psychiatry. 2014;14:259.
108. Segal SP, Silverman CJ, Temkin TL. Self-stigma and em- 125. Mosanya TJ, Adelufosi AO, Adebowale OT, Ogunwale A,
powerment in combined-CMHA and consumer-run services: Adebayo OK. Self-stigma, quality of life and schizophrenia:
two controlled trials. Psychiatr Serv. 2013;64(10):990–996. an outpatient clinic survey in Nigeria. Int J Soc Psychiatry.
109. Cavelti M, Rüsch N, Vauth R. Is living with psychosis de- 2014;60(4):377–386.
moralizing? Insight, self-stigma, and clinical outcome among 126. Vidović D, Brecić P, Vilibić M, Jukić V. Insight and self-
people with schizophrenia across 1 year. J Nerv Ment Dis. stigma in patients with schizophrenia. Acta Clin Croat.
2014;202(7):521–529. 2016;55(1):23–28.
110. Lysaker PH, Yanos PT, Outcalt J, Roe D. Association of 127. Ran MS, Zhang TM, Wong IY, et al. Internalized stigma in
stigma, self-esteem, and symptoms with concurrent and pro- people with severe mental illness in rural China. Int J Soc
spective assessment of social anxiety in schizophrenia. Clin Psychiatry. 2018;64(1):9–16.
Schizophr Relat Psychoses. 2010;4(1):41–48. 128. Firmin RL, Luther L, Salyers MP, Buck KD, Lysaker PH.
111. Pyle M, Stewart SL, French P, et al. Internalized stigma, Greater metacognition and lower fear of negative evaluation:
emotional dysfunction and unusual experiences in young potential factors contributing to improved stigma resist-
people at risk of psychosis. Early Interv Psychiatry. ance among individuals diagnosed with schizophrenia. Isr J
2015;9(2):133–140. Psychiatry Relat Sci. 2017;54(1):50–54.
112. Ritsher JB, Phelan JC. Internalized stigma predicts erosion 129. Kao YC, Lien YJ, Chang HA, Tzeng NS, Yeh CB, Loh CH.
of morale among psychiatric outpatients. Psychiatry Res. Stigma resistance in stable schizophrenia: the relative contri-
2004;129(3):257–265. butions of stereotype endorsement, self-reflection, self-esteem,
113. Rüsch N, Oexle N, Thornicroft G, et al. Self-contempt as a and coping styles. Can J Psychiatry. 2017;62(10):735–744.
predictor of suicidality: a longitudinal study. J Nerv Ment 130. Nabors LM, Yanos PT, Roe D, et al. Stereotype endorse-
Dis. 2019;207(12):1056–1057. ment, metacognitive capacity, and self-esteem as predictors
114. Rüsch N, Corrigan PW, Wassel A, et al. Self-stigma, of stigma resistance in persons with schizophrenia. Compr
group identification, perceived legitimacy of discrim- Psychiatry. 2014;55(4):792–798.
ination and mental health service use. Br J Psychiatry. 131. Chan KKS, Lee CWL, Mak WWS. Mindfulness model of
2009;195(6):551–552. stigma resistance among individuals with psychiatric dis-
115. Chio FHN, Mak WWS, Chan RCH, et al. Unraveling the in- orders. Mindfullness. 2018b;9:1433–1442.
sight paradox: one-year longitudinal study on the relation- 132. Campellone TR, Caponigro JM, Kring AM. The power
ships between insight, self-stigma, and life satisfaction among to resist: the relationship between power, stigma, and
people with schizophrenia spectrum disorders. Schizophr Res. negative symptoms in schizophrenia. Psychiatry Res.
2018;197:124–130. doi: S0920-9964(18)30034-30033. 2014;215(2):280–285.
116. Oexle N, Müller M, Kawohl W, et al. Self-stigma as a barrier 133. O’Connor LK, Yanos PT, Firmin RL. Correlates and mod-
to recovery: a longitudinal study. Eur Arch Psychiatry Clin erators of stigma resistance among people with severe mental
Neurosci. 2018;268(2):209–212. illness. Psychiatry Res. 2018;270:198–204.
117. Campbell DG, Bonner LM, Bolkan CR, et al. stigma predicts 134. Krendl AC, Pescosolido BA. Countries and cultural differ-
treatment preferences and care engagement among veterans ences in the stigma of mental illness: the east–west divide. J
affairs primary care patients with depression. Ann Behav Cross-Cult Psychol. 2020;51(2):149–167.
Med. 2016;50(4):533–544. 135. Alonso J, Buron A, Bruffaerts R, et al. Association of per-
118. Berry C, Greenwood K. Direct and indirect associations be- ceived stigma and mood and anxiety disorders: results from
tween dysfunctional attitudes, self-stigma, hopefulness and the World Mental Health Surveys. Acta Psychiatr Scand.
social inclusion in young people experiencing psychosis. 2008;118(4):305–314.
Schizophr Res. 2018;193:197–203. 136. Rose D, Willis R, Brohan E, et al. Reported stigma and dis-
119. Yanos PT, Lysaker PH, Roe D. Internalized stigma as a bar- crimination by people with a diagnosis of schizophrenia.
rier to improvement in vocational functioning among people Epidemiol Psychiatr Sci. 2011;20(2):193–204.
with schizophrenia-spectrum disorders. Psychiatry Res. 137. Üçok A, Karadayı G, Emiroğlu B, Sartorius N.
2010;178(1):211–213. Anticipated discrimination is related to symptom severity,
1284
functionality and quality of life in schizophrenia. Psychiatry health crisis team: a randomised controlled trial. Lancet.
Res. 2013;209(3):333–339. 2018;392(10145):409–418.
138. Lv Y, Wolf A, Wang X. Experienced stigma and self-stigma 155. Thornicroft G, Farrelly S, Szmukler G, et al. Clinical out-
in Chinese patients with schizophrenia. Gen Hosp Psychiatry. comes of Joint Crisis Plans to reduce compulsory treatment
2013;35(1):83–88. for people with psychosis: a randomised controlled trial.
139. Li J, Guo YB, Huang YG, et al. Stigma and discrimination ex- Lancet. 2013;381(9878):1634–1641.
perienced by people with schizophrenia living in the commu- 156. Ashcraft L, Bloss M, Anthony WA. Best practices: the de-
nity in Guangzhou, China. Psychiatry Res. 2017;255:225–231. velopment and implementation of “no force first” as a best
140. Yang LH, Thornicroft G, Alvarado R, Vega E, Link BG. practice. Psychiatr Serv. 2012;63(5):415–417.
Recent advances in cross-cultural measurement in psychi- 157. Meadows G, Brophy L, Shawyer F, et al. REFOCUS-
atric epidemiology: utilizing ‘what matters most’ to iden- PULSAR recovery-oriented practice training in specialist
tify culture-specific aspects of stigma. Int J Epidemiol. mental health care: a stepped-wedge cluster randomised con-
2014;43(2):494–510. trolled trial. Lancet Psychiatry. 2019;6(2):103–114.
141. Xu Z, Huang F, Kösters M, Rüsch N. Challenging mental 158. Browne J, Mueser KT, Meyer-Kalos P, Gottlieb JD,
health related stigma in China: systematic review and meta- Estroff SE, Penn DL. The therapeutic alliance in individual
analysis. II. Interventions among people with mental illness. resiliency training for first episode psychosis: relationship
Psychiatry Res. 2017;255:457–464. with treatment outcomes and therapy participation. J Consult
142. Special Eurobarometer n°248. Mental Well-being. 2006. Clin Psychol. 2019;87(8):734–744.
https://ec.europa.eu/health/ph_information/documents/ 159. Green MF, Horan WP, Lee J. Nonsocial and social cogni-
ebs_248_en.pdf. Accessed December 26, 2019. tion in schizophrenia: current evidence and future directions.
143. Special Eurobarometer n°345. Mental Health. 2010. https:// World Psychiatry. 2019;18(2):146–161.
ec.europa.eu/commfrontoffice/publicopinion/archives/ebs/ 160. Granholm E, Harvey PD. Social skills training for
ebs_345_en.pdf. Accessed December 26, 2019. negative symptoms of schizophrenia. Schizophr Bull.
144. Pescosolido BA, Medina TR, Martin JK, Long JS. The 2018;44(3):472–474.
“backbone” of stigma: identifying the global core of public 161. Xia J, Merinder LB, Belgamwar MR. Psychoeducation
prejudice associated with mental illness. Am J Public Health. for schizophrenia. Cochrane Database Syst Rev.
2013;103(5):853–860. 2011;15(6):CD002831.
145. Pew Research Center. Eastern and Western Europeans Differ 162. Dubreucq J, Ycart B, Gabayet F, et al. Towards an improved
on Importance of Religion, Views of Minorities, and Key Social access to psychiatric rehabilitation: availability and effect-
Issues. 2018. www.pewresearch.org. Accessed September 22, iveness at 1-year follow-up of psychoeducation, cognitive
2019. remediation therapy, cognitive behaviour therapy and so-
146. Pew Research Center. European Public Opinion Three Decades cial skills training in the FondaMental Advanced Centers of
After the Fall of Communism. 2019. www.pewresearch.org. Expertise-Schizophrenia (FACE-SZ) national cohort. Eur
Accessed September 22, 2019. Arch Psychiatry Clin Neurosci. 2019;269(5):599–610.
147. Gonzales L, Yanos PT, Stefancic A, Alexander MJ, Harney- 163. Pharoah F, Mari J, Rathbone J, et al. Family interven-
Delehanty B. The role of neighborhood factors and com- tion for schizophrenia. Cochrane Database Syst Rev.
munity stigma in predicting community participation 2010;(12):CD000088.
among persons with psychiatric disabilities. Psychiatr Serv. 164. Corrigan PW, Watson AC, Miller FE. Blame, shame, and con-
2018;69(1):76–83. tamination: the impact of mental illness and drug dependence
148. DeLuca JS, Vaccaro J, Seda J, Yanos PT. Political attitudes stigma of family members. J Fam Psychol. 2006;20:239–246.
as predictors of the multiple dimensions of mental health 165. Glynn SM, Cohen AN, Niv N. New challenges in family
stigma. Int J Soc Psychiatry. 2018;64(5):459–469. interventions for schizophrenia. Expert Rev Neurother.
149. Zhang YB, Lin MC, Nonaka A, et al. Harmony, hierarchy 2007;7(1):33–43.
and conservatism: a cross-cultural comparison of confucian 166. Vauth R, Bull N, Schneider G. Emotions- und stigmafokussierte
values in China, Korea, Japan, and Taiwan. Commun Res Angehörigenarbeit bei psychotischen Störungen. Göttingen:
Rep. 2005;22(2):107–115. Hogrefe; 2009.
150. Yang LH, Link BG, Ben-David S, et al. Stigma related to 167. Hasson-Ohayon I, Pijnenborg GHM, Ben-Pazi A, Taitel S,
labels and symptoms in individuals at clinical high-risk for Goldzweig G. Coping with information style and family burden:
psychosis. Schizophr Res. 2015;168(1–2):9–15. possible roles of self-stigma and hope among parents of children
151. Mulfinger N, Müller S, Böge I, et al. Honest, Open, Proud for in a psychiatric inpatient unit. Eur Psychiatry. 2017;42:8–13.
adolescents with mental illness: pilot randomized controlled 168. Morris E, Hippman C, Murray G, et al. Self-stigma in re-
trial. J Child Psychol Psychiatry. 2018;59(6):684–691. latives of people with mental illness scale: development and
152. James TT, Kutty VR. Assessment of internalized stigma validation. Br J Psychiatry. 2018;212(3):169–174.
among patients with mental disorders in Thiruvananthapuram 169. Grambal A, Prasko J, Kamaradova D, et al. Self-stigma in
district, Kerala, India. Asia Pac J Public Health. borderline personality disorder—cross-sectional comparison
2015;27(4):439–449. with schizophrenia spectrum disorder, major depressive
153. Segalovich J, Doron A, Behrbalk P, Kurs R, Romem P. disorder, and anxiety disorders. Neuropsychiatr Dis Treat.
Internalization of stigma and self-esteem as it affects the cap- 2016;12:2439–2448.
acity for intimacy among patients with schizophrenia. Arch 170. Kamaradova D, Latalova K, Prasko J, et al. Connection
Psychiatr Nurs. 2013;27(5):231–234. between self-stigma, adherence to treatment, and dis-
154. Johnson S, Lamb D, Marston L, et al. Peer-supported continuation of medication. Patient Prefer Adherence.
self-management for people discharged from a mental 2016;10:1289–1298.
1285
J. Dubreucq et al
171. Szcześniak D, Kobyłko A, Wojciechowska I, Kłapciński M, 187. Chronister J, Chou CC, Liao HY. The role of stigma coping
Rymaszewska J. Internalized stigma and its correlates among and social support in mediating the effect of societal stigma
patients with severe mental illness. Neuropsychiatr Dis Treat. on internalized stigma, mental health recovery, and quality
2018;14:2599–2608. of life among people with serious mental illness. J community
172. Sibitz I, Amering M, Unger A, et al. The impact of the psychol 2013;41:582–600.
social network, stigma and empowerment on the quality 188. Kira IA, Ramaswamy V, Lewandowski L, Mohanesh J,
of life in patients with schizophrenia. Eur Psychiatry. Abdul-Khalek H. Psychometric assessment of the Arabic
2011;26(1):28–33. version of the Internalized Stigma of Mental Illness (ISMI)
173. Galderisi S, Rossi A, Rocca P, et al. The influence of illness- measure in a refugee population. Transcult Psychiatry.
related variables, personal resources and context-related fac- 2015;52(5):636–658.
tors on real-life functioning of people with schizophrenia. 189. Tomar N, Brinkley-Rubinstein L, Ghezzi MA, Van Deinse TB,
World Psychiatry. 2014;13(3):275–287. Burgin S, Cuddeback GS. Internalized stigma and its correl-
174. Rossi A, Galderisi S, Rocca P, et al. The relationships of ates among justice-involved individuals with mental illness.
personal resources with symptom severity and psychosocial Int J Ment Health. 2019;49(20):1–11. doi:10.1080/00207411.
functioning in persons with schizophrenia: results from the 2019.1703358
Italian Network for Research on Psychoses study. Eur Arch 190. Jahn DR, Leith J, Muralidharan A, et al. The influence of
Psychiatry Clin Neurosci. 2017;267(4):285–294. experiences of stigma on recovery: mediating roles of intern-
175. Bouvet C, Bouchoux A. [Exploring the relationship between alized stigma, self-esteem, and self-efficacy. Psychiatr Rehabil
internalized stigma, insight and depression for inpatients J. 2020;43(2):97–105.
with schizophrenia]. Encephale. 2015;41(5):435–443. 191. Villotti P, Corbière M, Dewa CS, et al. A serial mediation
176. Vrbova K, Prasko J, Holubova M, et al. Self-stigma and model of workplace social support on work product-
schizophrenia: a cross-sectional study. Neuropsychiatr Dis ivity: the role of self-stigma and job tenure self-efficacy
Treat. 2016;12:3011–3020. in people with severe mental disorders. Disabil Rehabil.
177. Surmann M, Gruchalla LV, Falke S, et al. The importance of 2018;40(26):3113–3119.
strengthening competence and control beliefs in patients with 192. Firmin RL, Lysaker PH, Luther L, et al. Internalized stigma
psychosis to reduce treatment hindering self-stigmatization. in adults with early phase versus prolonged psychosis. Early
Psychiatry Res. 2017;255:314–320. Interv Psychiatry. 2019;13(4):745–751.
178. Holubova M, Prasko J, Matousek S, et al. Comparison 193. Link BG, Wells J, Phelan JC, Yang L. Understanding the im-
of self-stigma and quality of life in patients with depres- portance of “symbolic interaction stigma”: how expectations
sive disorders and schizophrenia spectrum disorders—a about the reactions of others adds to the burden of mental
cross-sectional study. Neuropsychiatr Dis Treat. illness stigma. Psychiatr Rehabil J. 2015;38(2):117–124.
2016;12:3021–3030. 194. Bassirnia A, Briggs J, Kopeykina I, Mednick A, Yaseen Z,
179. Uhlmann C, Kaehler J, Harris MS, Unser J, Arolt V, Galynker I. Relationship between personality traits and per-
Lencer R. Negative impact of self-stigmatization on attitude ceived internalized stigma in bipolar patients and their treat-
toward medication adherence in patients with psychosis. J ment partners. Psychiatry Res. 2015;230(2):436–440.
Psychiatr Pract. 2014;20(5):405–410. 195. Hill K, Startup M. The relationship between internalized
180. Post F, Pardeller S, Frajo-Apor B, et al. Quality of life in stigma, negative symptoms and social functioning in schizo-
stabilized outpatients with bipolar I disorder: associations phrenia: the mediating role of self-efficacy. Psychiatry Res.
with resilience, internalized stigma, and residual symptoms. 2013;206(2–3):151–157.
J Affect Disord. 2018;238:399–404. 196. Grover S, Avasthi A, Singh A, et al. Stigma experienced by pa-
181. Quenneville AF, Badoud D, Nicastro R, et al. Internalized tients with severe mental disorders: a nationwide multicentric
stigmatization in borderline personality disorder and atten- study from India. Psychiatry Res. 2017;257:550–558.
tion deficit hyperactivity disorder in comparison to bipolar 197. Maharjan S, Panthee B. Prevalence of self-stigma and its
disorder. J Affect Disord. 2020;262:317–322. association with self-esteem among psychiatric patients in
182. Lanfredi M, Zoppei S, Ferrari C, et al. Self-stigma as a medi- a Nepalese teaching hospital: a cross-sectional study. BMC
ator between social capital and empowerment among people Psychiatry. 2019;19(1):347.
with major depressive disorder in Europe: the ASPEN study. 198. Singh A, Mattoo SK, Grover S. Stigma and its correlates in
Eur Psychiatry. 2015;30(1):58–64. patients with schizophrenia attending a general hospital psy-
183. Ociskova M, Prasko J, Kamaradova D, Grambal A, chiatric unit. Indian J Psychiatry. 2016;58(3):291–300.
Sigmundova Z. Individual correlates of self-stigma in pa- 199. Pal A, Sharan P, Chadda RK. Internalized stigma and its im-
tients with anxiety disorders with and without comorbidities. pact in Indian outpatients with bipolar disorder. Psychiatry
Neuropsychiatr Dis Treat. 2015;11:1767–1779. Res. 2017;258:158–165.
184. Moritz S, Spirandelli K, Happach I, Lion D, Berna F. 200. Grover S, Hazari N, Aneja J, Chakrabarti S, Avasthi A.
Dysfunction by disclosure? Stereotype threat as a Stigma and its correlates among patients with bipolar dis-
source of secondary neurocognitive malperformance in order: a study from a tertiary care hospital of North India.
obsessive-compulsive disorder. J Int Neuropsychol Soc. Psychiatry Res. 2016;244:109–116.
2018;24(6):584–592.
201. Sahoo S, Grover S, Malhotra R, Avasthi A. Internalized
185. Boyd JE, Juanamarga J, Hashemi P. Stigma of taking psy-
stigma experienced by patients with first-episode depression:
chiatric medications among psychiatric outpatient veterans.
a study from a tertiary care center. Indian J Soc Psychiatry.
Psychiatr Rehabil J. 2015;38(2):132–134.
2018;34:21–29.
186. Drapalski AL, Lucksted A, Perrin PB, et al. A model of in-
202. Picco L, Pang S, Lau YW, et al. Internalized stigma
ternalized stigma and its effects on people with mental illness.
among psychiatric outpatients: associations with quality
Psychiatr Serv. 2013;64(3):264–269.
1286
of life, functioning, hope and self-esteem. Psychiatry Res. 212. Çapar M, Kavak F. Effect of internalized stigma on func-
2016;246:500–506. tional recovery in patients with schizophrenia. Perspect
203. Pribadi T, Lin EC, Chen PS, Lee SK, Fitryasari R, Psychiatr Care. 2019;55(1):103–111.
Chen CH. Factors associated with internalized stigma 213. Olçun Z, Şahin Altun Ö. The correlation between schizo-
for Indonesian individuals diagnosed with schizophrenia phrenic patients’ level of internalized stigma and their level
in a community setting. J Psychiatr Ment Health Nurs. of hope. Arch Psychiatr Nurs. 2017;31(4):332–337.
2020;27(5):584–594. 214. Yılmaz E, Okanlı A. The effect of internalized stigma on the
204. Kim EY, Jang MH. The mediating effects of self-esteem adherence to treatment in patients with schizophrenia. Arch
and resilience on the relationship between internal- Psychiatr Nurs. 2015;29(5):297–301.
ized stigma and quality of life in people with schizo- 215. Cerit C, Filizer A, Tural Ü, Tufan AE. Stigma: a core factor
phrenia. Asian Nurs Res (Korean Soc Nurs Sci). on predicting functionality in bipolar disorder. Compr
2019;13(4):257–263. Psychiatry. 2012;53(5):484–489.
205. Lu Y, Wang X. Correlation between insight and internal- 216. Sadighi G, Reza Khodaei M, Fadai F, et al. Self-stigma
ized stigma in patients with schizophrenia. Shanghai Arch among people with bipolar-I disorder in Iran. Iran Rehabil J.
Psychiatry. 2012;24(2):91–98. 2015;13(1):28–32.
206. Park K, MinHwa L, Seo M. The impact of self-stigma on 217. Adewuya AO, Owoeye AO, Erinfolami AO, Ola BA. Correlates
self-esteem among persons with different mental disorders. of self-stigma among outpatients with mental illness in Lagos,
Int J Soc Psychiatry. 2019;65(7–8):558–565. Nigeria. Int J Soc Psychiatry. 2011;57(4):418–427.
207. Woon LS, Khoo SI, Baharudin A, Midin M. Association be- 218. Asrat B, Ayenalem AE, Yimer T. Internalized stigma among
tween insight and internalized stigma and other clinical fac- patients with mental illness attending psychiatric follow-up
tors among patients with depression: a cross-sectional study. at Dilla University Referral Hospital, Southern Ethiopia.
Indian J Psychiatry. 2020;62(2):186–192. Psychiatry J. 2018;2018:1987581.
208. Ghanean H, Nojomi M, Jacobsson L. Internalized stigma of 219. Fadipe B, Adebowale TO, Ogunwale A, et al. Internalized
mental illness in Tehran, Iran. Stigma Research and Action stigma in schizophrenia: a cross-sectional study of prevalence
2011;1:11–17 and predictors. Int J Cult Ment Health. 2018;11(1):1–12. doi:
209. Tanriverdi D, Kaplan V, Bilgin S, et al. The comparison of 10.1080/17542863.2018.1450431
internalized stigmatization levels of patients with different 220. Assefa D, Shibre T, Asher L, Fekadu A. Internalized stigma
mental disorders. J Subst Use. 2019;25(3):251–257. doi: among patients with schizophrenia in Ethiopia: a cross-sectional
10.1080/14659891.2019.1675790 facility-based study. BMC Psychiatry. 2012;12:239.
210. Hasson-Ohayon I, Mashiach-Eizenberg M, Lysaker PH, 221. Lau YW, Picco L, Pang S, et al. Stigma resistance and its
Roe D. Self-clarity and different clusters of insight association with internalised stigma and psychosocial out-
and self-stigma in mental illness. Psychiatry Res. comes among psychiatric outpatients. Psychiatry Res.
2016;240:308–313. 2017;257:72–78.
211. Korkmaz G, Küçük L. Internalized stigma and perceived 222. Karakaş SA, Okanlı A, Yılmaz E. The effect of internalized
family support in acute psychiatric in-patient units. Arch stigma on the self-esteem in patients with schizophrenia. Arch
Psychiatr Nurs. 2016;30(1):55–61. Psychiatr Nurs. 2016;30(6):648–652.
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Schizophrenia Bulletin vol. 47 no. 5 pp.

Self-stigma in Serious Mental Illness: A Systematic Review of Frequency,

Julien Dubreucq*,1–3, , Julien Plasse4,5, and Nicolas Franck1,5,6

Self-stigma is associated with poor clinical and functional Introduction

Fig. 1. Review process (Prisma flow diagram)

Europe SMI Evans-Lacko51 Multi-site 1835 2.2 0.5 - -

Rusch58 Switzerland 186 1.9 0.6 - -

Area Study Country N Mean IS total score SD n High IS (%)

Pearl105 USA 319 2.11 0.53 - -

Area Study Country N Mean IS total score SD n High IS (%)

Table 3. Between-groups Differences by Geographical Area

Serious Mental Illness

Major depressive disorder

of studies relationship relationship lationship lationship

Table 5. Longitudinal Correlates and Consequences of Self-stigma

Correlates of increased self-stigma at follow-up

Area Study Country n Mean SR SD n High SR (%)

Europe SMI Grambal169 Czech Republic 184 2.52 0.57 - -

however, associated with improvements in QoL105 during

Turkey, Ethiopia,124 India, Bolivia,34 Peru,34 Chile,34

Metacognitive abilities,128–130 social network,123,131 social

Research on self-stigma in SMI has considerably pro-

gressed over the past decade (244 articles since 2010

and 28 studies published prior to this).7 Self-stigma was

self-stigma in all geographical areas (32.6%–44.2%). Self-

stigma in schizophrenia was higher in the Middle East,

South-East Asia, South Asia, and South America than in

Europe. Self-stigma differed according to the geograph-

countries could explain the higher levels of self-stigma in

South Asia and South-East Asia.134 Other potential fac-

of shame about not meeting the social expectations of

“what matters most” in one’s social group,14,16 moral or

cial concerns about the spillover effects disclosing mental

or anticipated stigma.3,135–137 Lower rates of experienced

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