Aspects of perceived stigma: The Stigma Inventory for Mental Illness, its development, latent structure and psychometric properties Maria Veroniki Karidi, Despoina Vasilopoulou, Eugenia Savvidou, Silia Vitoratou, Andreas D. Rabavilas, Constantinos N. Stefanis PII: DOI: Reference:

S0010-440X(14)00089-3 doi: 10.1016/j.comppsych.2014.04.002 YCOMP 51282

To appear in:

Comprehensive Psychiatry

Received date: Revised date: Accepted date:

19 June 2013 7 April 2014 7 April 2014

Please cite this article as: Karidi Maria Veroniki, Vasilopoulou Despoina, Savvidou Eugenia, Vitoratou Silia, Rabavilas Andreas D., Stefanis Constantinos N., Aspects of perceived stigma: The Stigma Inventory for Mental Illness, its development, latent structure and psychometric properties, Comprehensive Psychiatry (2014), doi: 10.1016/j.comppsych.2014.04.002

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Aspects of perceived stigma: the Stigma Inventory for Mental Illness, its development, latent structure and psychometric properties.

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Authors: *

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Maria Veroniki Karidi1, , Despoina Vasilopoulou1, Eugenia Savvidou1,

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Psychosocial Vocational Rehabilitation Unit (PVRU). University Mental Health Research

Institute (UMHRI), Athens, Greece.

Biostatistics Department, Institute of Psychiatry, King’s College London, UK.

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Silia Vitoratou2, Andreas D. Rabavilas1, Constantinos N Stefanis1

* Author of Correspondence:

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Dr. Maria Veroniki Karidi Psychosocial Vocational Rehabilitation Unit, University Mental Health Research Institute, 2 Soranou tou Efessiou 15601 Athens, Attica, Greece Phone: 00302106170915 Fax: 00302106170917 E-mail: [email protected]

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Aspects of perceived stigma: the Stigma Inventory for Mental Illness, its development, latent structure and psychometric properties.

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Authors: Maria Veroniki Karidi, Despoina Vasilopoulou, Eugenia Savvidou, Silia Vitoratou, Andreas

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D. Rabavilas, Constantinos N Stefanis

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Abstract

Objective: The aim of this study was to develop a new brief and easy to administer self-stigma scale for mental illness as well as to assess the correlations between self-stigma and psychopathology of

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chronic schizophrenic patients.

Methods: The Stigma Inventory for Mental Illness (SIMI) was administered to 100 outpatients

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diagnosed with schizophrenia. Psychopathology and overall functioning were assessed with the

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Positive and Negative Symptom Scale (PANSS) and Global Assessment Scale (GAS), respectively.

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Results: The final scale consists of 12 items. Factor analysis concluded to two dimensions: perceptions of social stigma and self-efficacy. Both factors were found to be reliable (high internal consistency and stability coefficients). Significant correlations were present with psychopathology, functioning and selected items from the Community Attitudes toward the Mentally Ill (CAMI) inventory.

Conclusion: The SIMI scale is a reliable and valid psychometric tool that can be used to assess patient’s self-stigma and self-efficacy. The findings suggest also that psychopathology has an immediate effect on endorsing self-stigmatizing attitudes.

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Introduction

Scientific literature indicates that everyday life and functioning of mentally ill patients are severely

considers stigma as a global health problem [2].

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affected by stigma. Given the universality of this tendency [1], the World Health Organization now

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Stigma is a general term composed of intertwined concepts, such as social, experienced and internalized stigma. Munoz et al. [3] define social stigma as the set of negative attitudes and beliefs that the public adopts towards mentally ill patients. Social stigma differs from experienced stigma in terms of the recipient of the stigmatizing attitudes; specifically, experienced stigma is - in a sense the consequence of social stigma, as it refers to the experienced discrimination due to the mental

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illness. Internalized (or self) stigma refers to “the stigma endorsed by the people suffering from a mental illness about them just for having their mental illness”. Other researchers argue that selfstigma is “a process of identity transformation wherein a person loses their previously held or

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desired identities to adopt a stigmatized view of themselves” [4].

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The nature of schizophrenia per se (both for acute or chronic states) seems to facilitate the endorsement of self-stigmatizing attitudes. The type and severity of the symptoms, the content of

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schizophrenic thoughts and ideas, the awareness that one may not control oneself and the chronic duration of the disorder are some of the illness’ characteristics that facilitate the emergence of a negative and stigmatized self-image. Schizophrenia can be conceived as erosion not only in the control of oneself but also in interpersonal relationships which is reflected in mistrust and dependence on institutions ultimately leading to the loss of social status [5]. This seems to aggravate patients’ internalizing stigma tendencies, which further interferes with their rehabilitation outcome, as suggested by evidence from clinical practice. It has been proposed that endorsing self-stigmatizing attitudes impedes the rehabilitation and integration process in multiple ways as patients tend to blame themselves for the illness’ onset, are inhibited from seeking help or job for fear of stigmatization [6] and withdraw from social interactions, altogether affecting their quality of life. Consequently, treating self-stigma should be a core component of every individualized therapeutic rehabilitation plan.

ACCEPTED MANUSCRIPT In this context emerged the need for the development of a clinical instrument that would assess self-

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stigmatizing attitudes in mentally ill patients.

Methods

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Participants

One hundred chronic patients with schizophrenia, who attended the Psychosocial Vocational Rehabilitation Unit (PVRU) of the University Mental Health Research Institute (UMHRI) were recruited. Inclusion criteria were: diagnosis of schizophrenia (according to the Diagnostic and Statistical Manual of Mental Disorders Revised [7]), stable symptomatology and compliance with the medication regime. Exclusion criteria were: substance abuse, developmental disabilities and

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neurological diseases. All patients were clinically examined and psychiatric records were formed, including clinical interviews of the patients and their close relatives. All individuals were unemployed

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upon entrance to the study.

The experimental design and procedure were reviewed and approved by the ethical committee of

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granted.

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the University Mental Health Research Institute and participants’ written informed consent was

Item development

The new scale was based on the Self-stigma Questionnaire (SSQ - [8]), developed by the PVRU of the UMHRI. The SSQ delivers detailed information to the clinicians with respect to the patients’ point of view towards their illness. However, clinical practice indicated the need for a short, robust psychometric scale for the evaluation of stigma, able to provide clinicians and researchers with a total score indicative of self-stigmatizing attitudes. By taking into consideration the experience granted by clinical practice and by the patients’ responses to SSQ throughout the years, a pool of 20 items was initially proposed by the members of a multidisciplinary research team (psychiatrists, psychologists, social workers and psychometricians). All items reflected stigma (no negatively/inversed scored items were included), measured on a 5-

ACCEPTED MANUSCRIPT point Likert scale varying from 1 (“no-never”) to 5 (“always”). The scale was designed to cover two areas: relations with oneself and relations with others, which include two distinct roles, the social and the professional role.

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The assessment of the psychometric properties of the items and the scale in total, led to the

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development of SIMI, a 12- item self-administered inventory, as described in detail at the following sections.

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Measures

The scale was administered during the first week of the patients’ participation in the program of the

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PVRU, in order to exclude potential effects of the rehabilitation program to the responses. At the same time, the patients’ pathology and functioning were evaluated by the program’s psychiatrists utilizing PANSS [9] and GAS [10].

Finally, the CAMI [11,12] inventory was administered

synchronously, which also assesses aspects of stigma and additionally is standardised in Greek language. Given that the CAMI evaluates mostly social stigma, only items referring to self-stigma

Statistical Analysis

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were considered.

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The factorial structure of the questionnaire was accessed via confirmatory factor analysis (using the robust weighted least squares estimator [13,14]). This methodology takes under consideration the ordinal nature of the items and is bias free as opposed to treating the Likert items as continuous

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indicators. For the model evaluation, two absolute fit indices are reported here, namely the Root Mean Square Error of Approximation (RMSEA) [15] and the relative chi-square [χ2/df; 16]. Furthermore, the fit of each model compared to the null (or independence) model was assessed by using two relative fit indices: the Tucker- Lewis index (TLI) and the Comparative Fit Index (CFI) [17].

With respect to the reliability of the scale, the internal consistency was assessed via Cronbach’s alpha coefficient (item level). Additionally, the test-retest reliability (stability) of the responses was evaluated in a time interval of one month, using Pearson’s correlation coefficient (for the total and factor scores). The content (concurrent) validity of the scale was evaluated on the basis of the correlations of the scale with the other measures. All analysis was undertaken using Mplus [18].

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Results

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Demographic and clinical characteristics

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The patients’ age (range: 22-68, mean=39.7, sd=9.4 years) and education level (first: 5%, second: 51%, third: 44%) did not differ significantly between genders. On the contrary, the mean age of the illness onset was significantly lower for females (19.4 versus 22.4, Mann-Whitney U=710.5, p=0.013).

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No significant differences were found between genders with regard to the psychopathology and level of functioning as measured by PANSS (mean: 83.8, sd-=22.4) and GAS (mean: 52.6, sd-=14.7)

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respectively. The majority of the individuals (82%) have been hospitalized at least once (in total, up to one month: 13, up to one year: 56 and more than a year: 13 individuals).

Item selection

Two criteria were implemented for item selection, that is, items that a) reduced the total scale’s

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reliability and/or b) provided loadings less than 0.2 (non-salient) in either the one-factor or the twofactor solutions (described below) were omitted from the scale. The exclusion procedure was conducted in a step-wise manner by re-evaluating at each point the consistency of the resulting set

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of items. The final scale consists of the 12 items presented in Table 1.

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TABLE 1 SHOULD BE PLACED HERE

Factor structure

The one (global) factor model was initially implemented, emerging adequate fit according to both relative and absolute measures of fit (see Table 2). Specifically, the relative chi-square value was lower than the threshold value of 2 and the RMSEA was 0.07 which indicates adequate fit according to Browne and Cudeck [15]. The relative fit indices (TLI and CFI) were higher than the threshold of 0.9, confirming close fit. The next step of the analysis was to evaluate the fit of multidimensional, theory-oriented models suggested by the members of our research team. CFA results indicated that the best fitted model is the two factor solution presented in Table 2. The fit indices were further improved (compared to the global factor solution), while the context of the items further justified the factorial structure, in terms of face validity.

ACCEPTED MANUSCRIPT Based on the content of the items that load to each factor, the two dimensions identified are hereafter referred to as the “perceptions of social stigma” and the “self-efficacy” factors (see also

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Table 1).

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TABLE 2 SHOULD BE PLACED HERE

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Reliability assessment

The alpha coefficient was 0.90 for the total score and 0.85 and 0.75 for the first and second factors respectively. These values are considered satisfactory, especially since the second factor is consisted of four items while the alpha coefficient is dependent upon the number of items. Test-retest reliability was evaluated by re-assessing a random sub-sample of 40 patients within one

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month. The correlation of the total scores between assessments was 0.8 (p

Aspects of perceived stigma: the Stigma Inventory for Mental Illness, its development, latent structure and psychometric properties.

The aim of this study was to develop a new brief and easy to administer self-stigma scale for mental illness as well as to assess the correlations bet...
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