513442 research-article2013
ISP0010.1177/0020764013513442International Journal of Social Psychiatry
E CAMDEN SCHIZOPH
Article
Loneliness mediates the relationship between internalised stigma and depression among patients with psychotic disorders
International Journal of Social Psychiatry 2014, Vol. 60(8) 733–740 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764013513442 isp.sagepub.com
Piotr S’witaj1, Paweł Grygiel2, Marta Anczewska1 and Jacek Wciórka1
Abstract Background: Stigmatisation is a source of chronic stress and a major barrier to recovery for people with mental illnesses. The internalisation of stigma can have a negative impact on an individual’s social relations and lead to feelings of loneliness and depression. Aim: This research is aimed at testing the hypothesis that the internalised stigma of mental illness contributes to the intensification of depressive symptoms indirectly, through its impact on feelings of loneliness. Methods: A total of 110 individuals with diagnoses of psychotic disorders (International Classification of Diseases–10th Revision (ICD-10): F20–F29) were assessed with measures of internalised stigma, loneliness, depression, positive and negative symptoms and global functioning. The ordinary least squares regression was used for data analysis. Results: After adding loneliness to the regression model, the initially significant impact of internalised stigma on depressive symptoms disappeared. As expected, loneliness proved to be a full mediator in the relationship between stigma and depression. Conclusion: The study findings provide useful insights into the mechanisms of the harmful effects of stigma on people with mental illness. Internalised stigma and loneliness should be considered important targets for interventions aiming to promote recovery. Keywords Stigma, loneliness, depression, mental illness
Introduction Stigmatisation is a source of chronic stress and a major barrier to recovery for people with mental illnesses (Corrigan, 2005; van Zelst, 2009). According to Corrigan’s (2005) theoretical model, social stigma consists of three main elements: stereotypes, prejudice and discrimination. Thornicroft, Rose, Kassam and Sartorius (2007) define stigma in a similar way, describing it in terms of problems of knowledge (ignorance), attitudes (prejudice) and behaviour (discrimination). There is a consensus that widespread negative attitudes in society towards people with mental illness (i.e. public stigma) are only one aspect of the problem. No less important are the attitudes and reactions of the stigmatised themselves, who often accept and relate to themselves negative stereotypes of mental illness, which results in lower self-esteem, lack of faith in the efficacy of their own actions and the abandonment of efforts to achieve important life goals (Corrigan, 2005; Corrigan, Larson, & Rüsch, 2009). This phenomenon is referred to as self-stigma or internalised stigma.
Previous studies have shown that internalised stigma of mental illness may contribute to the severity of depressive symptoms (Link, Struening, Rahav, Phelan, & Nuttbrock, 1997; Ritsher & Phelan, 2004; Sibitz, Amering, et al., 2011; Vauth, Kleim, Wirtz, & Corrigan, 2007; Yanos, Roe, Markus, & Lysaker, 2008). However, the exact mechanism of this effect is not well understood. Vauth et al. (2007) proposed a model whereby the effect of self-stigma on depression is mediated by self-efficacy and empowerment. Yanos et al. (2008) have demonstrated that internalised stigma can affect depression through its influence on hope and self-esteem. In this study, we submit to empirical 1I
Department of Psychiatry, Institute of Psychiatry and Neurology, Warsaw, Poland 2Educational Research Institute, Warsaw, Poland Corresponding author: Piotr S’witaj, I Department of Psychiatry, Institute of Psychiatry and Neurology, ul. Sobieskiego 9, 02-957 Warsaw, Poland. Email: [email protected]
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verification yet another possible mechanism of the impact of stigma on depression – through a sense of loneliness. Loneliness can be defined as ‘a situation experienced by the individual as one where there is an unpleasant or inadmissible lack of (quality of) certain relationships’ (De Jong Gierveld, 1987, p. 120). This phenomenon is related, above all, to the failure to satisfy the need for intimacy, and it arises on the basis of the differences between ideal and actually perceived interpersonal relationships. It is basically a subjective experience and, as such, should be distinguished from social isolation, which concerns the objective characteristics of the situation and refers to the absence of relationships with other people (De Jong Gierveld, van Tilburg, & Dykstra, 2006). That is to say, socially isolated persons are not necessarily lonely, and vice versa. Most people at least occasionally experience loneliness (Heinrich & Gullone, 2006), yet individuals with mental illness are among the groups particularly exposed to its severe and persistent forms (Ernst & Cacioppo, 1999; Perese & Wolf, 2005; West, Kellner, & Moore-West, 1986). A study conducted on a representative sample of the population of England showed that all mental disorders were strongly associated with feelings of loneliness, and in the case of people with two or three mental disorders, there was an approximately 20-fold increase in odds of loneliness compared with those with no mental disorder (Meltzer et al., 2013). Stigmatisation is considered to be one of the main reasons for experiencing loneliness among persons with mental illness (Perese & Wolf, 2005). The most obvious manifestation of the effect that stigma has on breaking the individual’s social ties is rejection by others and discrimination in many areas of life (Wahl, 1999). However, people with mental illness might also withdraw themselves from social contacts for fear of rejection (Corrigan et al., 2009; Link, Cullen, Struening, Shrout, & Dohrenwend, 1989). It has been found that self-stigma may affect various aspects of the social integration of people receiving psychiatric treatment, such as social networks and interpersonal relationships (Link et al., 1989; Lysaker, Davis, Warman, Strasburger, & Beattie, 2007; Perlick et al., 2001) or the sense of belonging in the community (Prince & Prince, 2002). Nonetheless, we are not familiar with any empirical study that directly assessed the impact of internalised stigma of mental illness on the feelings of loneliness. A review of studies regarding the relationship between loneliness and depression has shown that these two are in fact separate yet closely related phenomena (Cacioppo & Hawkley, 2009; Heinrich & Gullone, 2006). The results of some longitudinal studies carried out on non-clinical populations suggest that while loneliness and depression are mutually dependent in time, the impact of the sense of loneliness on depressive symptoms is greater (Vanhalst, Klimstra, et al., 2012) and more stable (Vanhalst, Luyckx,
Teppers, & Goossens, 2012) than that of depression on loneliness. It follows that stigmatisation can lead to loneliness, which in turn is recognised as a predictor of depression. The aim of this study is to test the hypothesis that loneliness is a full mediator in the relationship between internalised stigma and depression among people with psychotic disorders.
Method Participants A convenience sample of psychiatric patients was recruited from several mental health-care facilities in Warsaw (Poland). The inclusion criteria were as follows: (1) diagnosis of non-affective psychotic disorder (International Classification of Diseases–10th Revision (ICD-10): F20– F29); (2) age over 18 years; (3) written, informed consent to participate in the study; and (4) a stable mental state, according to the attending psychiatrist, good enough to understand the questions and complete the set of questionnaires accurately. Patients with active drug or alcohol dependence, organic brain disease, severe cognitive deficits or documented mental retardation were excluded. Altogether, the study included 110 patients. Table 1 presents the socio-demographic and clinical characteristics of the sample.
Measures Self-stigma was assessed with the aid of the Internalised Stigma of Mental Illness (ISMI) scale (Ritsher, Otilingam, & Grajales, 2003). This is a self-report questionnaire consisting of 29 items, grouped into five sub-scales: alienation, stereotype endorsement, discrimination experience, social withdrawal and stigma resistance. Answers to the ISMI statements are given on a 4-point scale from 1 (definitely disagree) to 4 (definitely agree). A global score is calculated by summing up the ratings of individual items and then dividing the total by the number of items. A higher score stands for higher stigma. As it has been shown that the stigma resistance sub-scale has weaker psychometric properties than the other four sub-scales (Ritsher et al., 2003), and it measures a separate theoretical construct (Sibitz, Unger, Woppmann, Zidek, & Amering, 2011), in this study, it was not included in the total scale score. In our sample, Cronbach’s α for the ISMI was found to be .94. Loneliness was measured by a short version of the De Jong Gierveld Loneliness Scale (DJGLS; De Jong Gierveld & Kamphuis, 1985; De Jong Gierveld & van Tilburg, 2006). This instrument consists of six items, to which the interviewees respond using a 5-point scale ranging from 1 (strongly agree) to 5 (strongly disagree). It can be used to assess both the overall level of loneliness and two of its
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Table 1. Socio-demographic and clinical characteristics of the participants (N = 110). Characteristic Sex Men Women Age (years) Living situation Alone With family of origin With own family With others Education Secondary or lower Higher Place of residence Village or small town (50,000 residents) Employment status Employed Not employed Diagnosis (ICD-10 code) Schizophrenia (F20) Schizotypal disorder (F21) Persistent delusional disorder (F22) Acute psychotic disorder (F23) Induced delusional disorder (F24) Schizoaffective disorder (F25) Other nonorganic psychotic disorder (F28) Type of psychiatric facility Inpatient ward Day ward Community mental health centre Outpatient clinic Duration of illness (years) Number of psychiatric inpatient hospitalisations
n (%)/mean (SD) 43 (39.1%) 67 (60.9%) 38.4 (11.4) 25 (22.7) 62 (56.4) 18 (16.4) 5 (4.5) 71 (64.5) 39 (35.5) 25 (22.7) 85 (77.3) 28 (25.5) 82 (74.5) 93 (84.5) 2 (1.8) 4 (3.6) 3 (2.7) 1 (0.9) 6 (5.5) 1 (0.9)
33 (30.0) 72 (65.5) 3 (2.7) 2 (1.8) 12.4 (10.5) 4.9 (4.9)
SD: standard deviation; ICD-10: International Classification of Diseases–10th Revision.
dimensions: emotional (3 items) and social (3 items). After recoding the three items referring to the emotional aspects of loneliness, a higher total score indicates a more intense global sense of loneliness. Cronbach’s α for the DJGLS in this study was .83. The intensity of depressive symptoms was evaluated by means of the Calgary Depression Scale for Schizophrenia (CDSS; Addington, Addington, & Schissel, 1990). The scale includes nine items which are rated by a clinician on a scale from 0 (absence of a symptom) to 3 (severe symptom). In this study, the value of Cronbach’s α for the CDSS was .82.
The overall functioning of the participants was measured with the use of the Global Assessment of Functioning (GAF) Scale (American Psychiatric Association, 1994). The GAF takes into account three aspects of functioning: psychological, interpersonal and occupational. The assessment is made by a clinician on a scale ranging from 1 (the worst possible functioning) to 100 (the best possible functioning). In this study, it was the highest level of functioning in the past year that was evaluated. The severity of psychopathological symptoms was assessed using the standard version of the Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1988). This instrument comprises 18 items scored by a clinician on a scale which ranges from 1 (symptom not present) to 7 (symptom extremely severe). Two out of five BPRS subscales, differentiated by Shafer (2005) on the basis of a meta-analysis of factor analyses of the scale, have been selected for the purposes of this study: positive symptoms (unusual thought content, conceptual disorganisation, hallucinatory behaviour and grandiosity) and negative symptoms (blunted affect, emotional withdrawal and motor retardation). In the current sample, the values of Cronbach’s α for the sub-scales of positive and negative symptoms were .60 and .74, respectively. Means and standard deviations for the instruments used in the study are presented in Table 2.
Procedures The data used in this article are part of a larger project aimed at the analysis of the factors that have an impact on the recovery of persons with mental illness. The study was approved by the Bioethical Committee at the Institute of Psychiatry and Neurology (IPiN) in Warsaw. In each participating service, eligible patients were identified by staff psychiatrists. They were then approached by the members of the research team, who invited them to take part in the study. All participants provided their informed consent. Socio-demographic and clinical data were collected on the basis of information obtained from the patients and analysis of available medical records. Self-report questionnaires (ISMI, DJGLS) were filled out by the respondents – depending on preference – in private or in the presence (and, if necessary, with the help) of the researcher. The CDSS, GAF and BPRS were completed by trained psychologists and psychiatrists.
Data analysis Descriptive statistics. Means and standard deviations or percentages, as appropriate, for all study variables, Cronbach’s α coefficients for the instruments used, and Pearson product–moment correlations between the key variables were calculated by means of IBM SPSS Statistics version 21 (SPSS Inc., Chicago, IL).
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Table 2. Means and standard deviations (SDs) for the instruments used in the study (N = 110). Instrument
Mean (SD)
ISMIa DJGLSb CDSSc GAFd Positive symptoms sub-scale of the BPRSe Negative symptoms sub-scale of the BPRSf
2.39 (0.53) 17.13 (5.14) 5.81 (4.47) 54.57 (14.84) 7.84 (3.64) 8.26 (3.41)
ISMI: Internalised Stigma of Mental Illness; DJGLS: De Jong Gierveld Loneliness Scale; CDSS: Calgary Depression Scale for Schizophrenia; GAF: Global Assessment of Functioning; BPRS: Brief Psychiatric Rating Scale. aPossible scores range from 1 to 4, with higher scores indicating more severe stigma. bPossible scores range from 6 to 30, with higher scores indicating more severe sense of loneliness. cPossible scores range from 0 to 27, with higher scores indicating more severe depressive symptoms. dPossible scores range from 1 to 100, with higher scores indicating better psychosocial functioning. ePossible scores range from 4 to 28, with higher scores indicating more severe positive symptoms. fPossible scores range from 3 to 21, with higher scores indicating more severe negative symptoms.
Figure 1. Schematic model with loneliness as the mediator in the relationship between internalised stigma and depression.
IV: independent variable (predictor); DV: dependent variable; MV: mediator variable. Path c represents the total effect of internalised stigma on depression (without considering the mediating effect of loneliness). Path a refers to the direct impact of internalised stigma on loneliness. Path b depicts the direct impact of loneliness on depression after controlling for internalised stigma. Path c′ represents the direct impact of internalised stigma on depression after controlling for loneliness. The indirect effect of internalised stigma on depression via loneliness is calculated as the product of the direct effects of internalised stigma on loneliness and loneliness on depression (a × b).
Mediation analysis. According to Baron and Kenny (1986), a mediating relationship exists if (1) the independent variable (IV) predicts the presumed mediator variable (MV); (2) the MV predicts the dependent variable (DV), controlling for the IV; (3) after controlling for the effects of the MV, a previously significant relationship between the IV and the DV becomes non-significant (full or perfect mediation) or weaker (partial mediation). Thus, following the procedure proposed by Baron and Kenny, the analyses of the role of loneliness in mediating the relationship between internalised stigma and depression were planned in several stages (see Figure 1). The starting point was to verify the significance of the relationship between internalised stigma and depression,
without considering the mediating effect of loneliness (path c). In the next step, the impact of stigma on loneliness was assessed (path a). In the final model, we tested the influence of loneliness on depression, controlling for the effects of stigma (path b), and the influence of stigma on depression, controlling for loneliness (path c′). In all analyses conducted, the following socio-demographic and clinical background characteristics were used as covariates: sex, age, place of residence, level of education, living situation, employment status, duration of illness, type of psychiatric facility, number of psychiatric inpatient hospitalisations, the level of psychosocial functioning assessed by the GAF scale and the severity of positive and negative symptoms measured by the BPRS sub-scales. The hypothesised mediation model was analysed using the PROCESS macro for SPSS (Hayes, 2013), based on ordinary least squares (OLS) regression. The bootstrapping procedure developed by Preacher and Hayes (2008) was applied for testing the significance of the indirect effect. Unlike traditional tests, such as the Sobel test (Sobel, 1982), bootstrapping does not require the assumption of a normal distribution of the indirect effect, difficult to meet especially for small research samples. We used 50,000 bootstrap resamples to calculate the bias-corrected 95% confidence interval (CI). If the interval does not include zero, the effect is statistically significant at p < .05.
Results Correlations between key study variables are presented in Table 3. As expected, internalised stigma, loneliness and depression were all significantly positively correlated with each other. Table 4 shows the results of the regression analyses testing the mediating effect of loneliness on the relationship between internalised stigma and depression.
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Table 3. Pearson correlations between internalised stigma, loneliness, depression, positive and negative symptoms and global functioning (N = 110). Variable
1
1. ISMI 2. DJGLS 3. CDSS 4. GAF 5. Positive symptoms (BPRS) 6. Negative symptoms (BPRS)
–
2
.44** .32** −.09 −.09 .11
3
4
5
6
– .36** −.07 .02 .03
– −.21* .01 .11
– −.46** −.54**
– .39**
–
ISMI: Internalised Stigma of Mental Illness; DJGLS: De Jong Gierveld Loneliness Scale; CDSS: Calgary Depression Scale for Schizophrenia; GAF: Global Assessment of Functioning; BPRS: Brief Psychiatric Rating Scale. *p < .05, **p < .01.
The unstandardised regression coefficient for path c turned out to be statistically significant: t(97) = 2.44, p < .05. The positive value of the coefficient (B = 2.41, standard error (SE) = .99) indicates that as the level of internalised stigma increases – with socio-demographic and clinical variables controlled – the level of depression also grows. The unstandardised regression coefficient for path a was also positive (B = 3.72, SE = 1.15) and significant: t(97) = 3.23, p < .01. This means that a more intense internalised stigma is associated with a higher sense of loneliness. The regression coefficient for path b was significantly different from zero as well: t(96) = 3.05, p < .01. Its positive value (B = .27, SE = .09) indicates that as the sense of loneliness grows, so does the intensity of depressive symptoms. What is important in the context of our hypotheses is that the direct impact of stigma on depression (path c′) proved to be statistically non-significant: t(96) = 1.35, p = .18. When both stigma and loneliness were introduced to the regression equation, the effect of loneliness remained significant, but the effect of stigma did not. At the same time, the bias-corrected bootstrap 95% CI did not contain zero (.29, 2.14), showing that the indirect impact of internalised stigma on depression through loneliness (B = 1.01, SE = .47) was statistically significant. Taken together, these findings support the full mediation hypothesis.
Discussion In this study, we have analysed the associations between internalised stigma, loneliness and depression among a sample of patients with psychotic disorders. We found support for the hypothesis that even after controlling for sociodemographic and clinical background characteristics, self-stigma contributes to depressive symptoms, with this effect being fully mediated by feelings of loneliness. While the link between stigma and depression was consistently identified in the literature (Link et al., 1997; Ritsher & Phelan, 2004; Sibitz, Amering, et al., 2011; Vauth et al., 2007; Yanos et al., 2008), our results are a step forward in clarifying the mechanism underlying this relationship.
Previous research demonstrated the role of various selfconcept variables, such as self-efficacy and empowerment (Vauth et al., 2007), or self-esteem and hopefulness (Yanos et al., 2008), in mediating the relationship between selfstigma and the severity of depressive symptoms. This study adds to these findings by showing that internalised stigma may lead to depression not only by changing the way people perceive and feel about themselves but also by affecting their perception of their social relations. Future studies should explore the mutual relationships between loneliness and various aspects of self-concept in the process of stigmatisation. The results of this research have important implications for clinical practice. They indicate that internalised stigma may impede the process of recovery of people with mental illness and therefore needs to be addressed in the therapeutic programmes. A review of empirical studies of self-stigma reduction strategies identified two prominent approaches in this area: interventions directed at correcting the stigmatising beliefs and attitudes of the individual and interventions attempting to enhance the individual’s skills for coping with self-stigma through improvements in self-esteem, empowerment and help-seeking behaviour (Mittal, Sullivan, Chekuri, Allee, & Corrigan, 2012). Our study suggests that counteracting the harmful effects of self-stigmatisation should also involve interventions aimed at reducing the individual’s feelings of loneliness. Researchers distinguish four primary strategies of loneliness reduction interventions: improving social skills, enhancing social support, increasing opportunities for social contact and addressing maladaptive social cognition (Masi, Chen, Hawkley, & Cacioppo, 2011). Although some evidence exists that the most successful strategy is addressing deficits in social cognition (Masi et al., 2011), in practice, the selection of appropriate interventions for people with severe mental illness should be made after careful consideration of such factors as the person’s residual disabilities and existing social network, the characteristics of the interventions, their effectiveness, the likelihood of a good fit between the person and the intervention, and the availability of interventions in the community (Perese & Wolf, 2005).
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0.99 – 1.18 0.06 1.20 1.08 1.14 1.24 0.06 0.94 0.09 0.04 0.16 0.20 4.60
2.41* – −0.79 −0.02 −0.36 −1.43 0.48 0.95 −0.00 −0.22 −0.12 −0.06 0.01 −0.09 5.06 0.19 1.70*
SE
−0.11 −0.05 0.01 −0.08 2.10 0.26 2.18*
0.01 0.07
1.46
1.00
−0.96
1.40 0.27** −0.87 −0.04 −0.37
B
0.09 0.04 0.16 0.19 4.56
0.06 0.88
1.20
1.06
1.00
1.03 0.09 1.21 0.06 1.21
SE
path c′ and path b
path c B
Direct effects of stigma on depression and loneliness on depression
Total effect of stigma on depression
0.31 0.10 0.02
3.72**
−0.03 −0.03 0.03 −0.03 10.90 0.27 3.84**
−0.03 −1.07
−1.90
−1.90
−1.74
–
B
path a
–
0.12 0.04 0.20 0.20 5.60
0.08 1.33
1.28
1.32
1.21
1.20 0.07 1.22
1.15
SE
Direct effect of stigma on loneliness
1.01*
B
0.47
SE
path a × b
0.29
Lower
2.14
Upper
CI for indirect effect
Indirect effect of stigma on depression
SE: standard error; CI: confidence interval; ISMI: Internalised Stigma of Mental Illness, DJGLS: De Jong Gierveld Loneliness Scale; GAF: Global Assessment of Functioning; BPRS: Brief Psychiatric Rating Scale. *p < .05, **p < .01.
Internalised stigma (ISMI) Loneliness (DJGLS) Covariates Sex (0 – women, 1 – men) Age Place of residence (0 – village or small town < 50,000 residents, 1 – town above 50,000 residents) Education (0 – secondary or lower, 1 – higher) Living situation (0 – living alone, 1 – living with someone) Employment (0 – employed, 1 – not employed) Duration of illness Psychiatric facility (0 – inpatient ward, 1 – other) Number of inpatient hospitalisations Global functioning (GAF) BPRS positive symptoms BPRS negative symptoms Constant R2 F
Variable
Table 4. Results of the regression analyses testing the mediating effect of loneliness on the relationship between internalised stigma and depression (N = 110).
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A few methodological limitations of this study need to be recognised. First, the cross-sectional nature of the data makes it impossible to draw definitive conclusions about the direction of the relationships found. We cannot rule out the possibility that depression leads to an increase in both loneliness and self-stigma; therefore, it is necessary to verify our results in studies with a longitudinal design. Furthermore, we used a relatively small convenience sample, which may not be representative of the entire population of people with mental illness in Poland. We should also mention the limitations imposed by the method of measurement of internalised stigma. Although the ISMI is one of the most frequently used (Livingston & Boyd, 2010) and one of the highest rated in terms of its psychometric properties (Brohan, Slade, Clement, & Thornicroft, 2010), measures of the subjective experience of the stigma of mental illness, the reliability and validity of its Polish version have not yet been systematically studied. Besides, this instrument does not assess the implicit aspects of self-stigma, which may also be clinically significant (Rüsch, Corrigan, Todd, & Bodenhausen, 2010). It is also worth noting that our analysis has taken into account only a generalised sense of loneliness. It seems possible that internalised stigma and depression are differentially associated with various dimensions of loneliness (e.g. social and emotional loneliness) and/or forms of loneliness experienced in different relationships (e.g. with friends, family members or romantic partners) – this needs to be explored in future studies, using multidimensional measures of loneliness, such as, for example, the Social and Emotional Loneliness Scale for Adults (SELSA; DiTommaso & Spinner, 1993). Finally, it cannot be excluded that some unmeasured variables account for the associations we observed. In conclusion, our study provides useful insights into the mechanisms of the harmful effects of stigma on people receiving psychiatric treatment. The results obtained support the view that self-stigmatising attitudes increase an individual’s sense of loneliness, which is a crucial marker of social relationship deficits (Heinrich & Gullone, 2006), thus contributing to the development of depressive symptoms. Internalised stigma and loneliness should be considered important targets for interventions aiming to promote recovery from mental illness. Acknowledgements We wish to express our thanks to the following colleagues for their help in recruiting patients and collecting the data: Joanna Krzyżanowska, Aleksandra Kur, Monika Lis-Szymczak, Alicja Multarzyńska, Magdalena Musiałowicz-Paterek, Urszula OlbryśBańkowska, Dorota Parnowska, Katarzyna Romanowicz, Izabela Stefaniak, Ewa Winkler, Tomasz Grzegorczyk and Sławomir Pietrak. We also thank two anonymous reviewers for their constructive comments on an earlier version of this article.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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Link, B. G., Struening, E. L., Rahav, M., Phelan, J. C., & Nuttbrock, L. (1997). On stigma and its consequences: Evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. Journal of Health and Social Behavior, 38, 177–190. Livingston, J. D., & Boyd, J. E. (2010). Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis. Social Science & Medicine, 71, 2150–2161. Lysaker, P. H., Davis, L. W., Warman, D. M., Strasburger, A., & Beattie, N. (2007). Stigma, social function and symptoms in schizophrenia and schizoaffective disorder: Associations across 6 months. Psychiatry Research, 149, 89–95. Masi, C. M., Chen, H. Y., Hawkley, L. C., & Cacioppo, J. (2011). A meta-analysis of interventions to reduce loneliness. Personality and Social Psychology Review, 15, 219–266. Meltzer, H., Bebbington, P., Dennis, M. S., Jenkins, R., McManus, S., & Brugha, T. (2013). Feelings of loneliness among adults with mental disorder. Social Psychiatry and Psychiatric Epidemiology, 48, 5–13. Mittal, D., Sullivan, G., Chekuri, L., Allee, E., & Corrigan, P. W. (2012). Empirical studies of self-stigma reduction strategies: A critical review of the literature. Psychiatric Services, 63, 974–981. Overall, J. E., & Gorham, D. R. (1988). The Brief Psychiatric Rating Scale (BPRS): Recent developments in ascertainment and scaling. Psychopharmacology Bulletin, 24, 97–99. Perese, E. F., & Wolf, M. (2005). Combating loneliness among persons with severe mental illness: Social network interventions’ characteristics, effectiveness, and applicability. Issues in Mental Health Nursing, 26, 591–609. Perlick, D. A., Rosenheck, R. A., Clarkin, J. F., Sirey, J. A., Salahi, J., Struening, E. L., & Link, B. G. (2001). Adverse effects of perceived stigma on social adaptation of persons diagnosed with bipolar affective disorder. Psychiatric Services, 52, 1627–1632. Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879–891. Prince, P. N., & Prince, C. R. (2002). Perceived stigma and community integration among clients of assertive community treatment. Psychiatric Rehabilitation Journal, 25, 323–331. Ritsher, J. B., Otilingam, P. G., & Grajales, M. (2003). Internalized stigma of mental illness: Psychometric properties of a new measure. Psychiatry Research, 121, 31–49.
Ritsher, J. B., & Phelan, J. C. (2004). Internalized stigma predicts erosion of morale among psychiatric outpatients. Psychiatry Research, 129, 257–265. Rüsch, N., Corrigan, P. W., Todd, A. R., & Bodenhausen, G. V. (2010). Implicit self-stigma in people with mental illness. The Journal of Nervous and Mental Disease, 198, 150–153. Shafer, A. (2005). Meta-analysis of the Brief Psychiatric Rating Scale factor structure. Psychological Assessment, 17, 324–335. Sibitz, I., Amering, M., Unger, A., Seyringer, M. E., Bachmann, A., Schrank, B., & Woppmann, A. (2011). The impact of the social network, stigma and empowerment on the quality of life in patients with schizophrenia. European Psychiatry, 26, 28–33. Sibitz, I., Unger, A., Woppmann, A., Zidek, T., & Amering, M. (2011). Stigma resistance in patients with schizophrenia. Schizophrenia Bulletin, 37, 316–323. Sobel, M. E. (1982). Asymptotic confidence intervals for indirect effects in structural equation models. Sociological Methodology, 13, 290–312. Thornicroft, G., Rose, D., Kassam, A., & Sartorius, N. (2007). Stigma: Ignorance, prejudice or discrimination? The British Journal of Psychiatry, 190, 192–193. Vanhalst, J., Klimstra, T. A., Luyckx, K., Scholte, R. H. J., Engels, R. C. M. E., & Goossens, L. (2012). The interplay of loneliness and depressive symptoms across adolescence: Exploring the role of personality traits. Journal of Youth and Adolescence, 41, 776–787. Vanhalst, J., Luyckx, K., Teppers, E., & Goossens, L. (2012). Disentangling the longitudinal relation between loneliness and depressive symptoms: Prospective effects and the intervening role of coping. Journal of Social and Clinical Psychology, 31, 810–834. van Zelst, C. (2009). Stigmatization as an environmental risk in schizophrenia: A user perspective. Schizophrenia Bulletin, 35, 293–296. Vauth, R., Kleim, B., Wirtz, M., & Corrigan, P. W. (2007). Selfefficacy and empowerment as outcomes of self-stigmatizing and coping in schizophrenia. Psychiatry Research, 150, 71–80. Wahl, O. F. (1999). Mental health consumers’ experience of stigma. Schizophrenia Bulletin, 25, 467–478. West, D. A., Kellner, R., & Moore-West, M. (1986). The effects of loneliness: A review of the literature. Comprehensive Psychiatry, 27, 351–363. Yanos, P. T., Roe, D., Markus, K., & Lysaker, P. H. (2008). Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatric Services, 59, 1437–1442.
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ISP0010.1177/0020764013513442International Journal of Social Psychiatry
E CAMDEN SCHIZOPH
Article
Loneliness mediates the relationship between internalised stigma and depression among patients with psychotic disorders
International Journal of Social Psychiatry 2014, Vol. 60(8) 733–740 © The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764013513442 isp.sagepub.com
Piotr S’witaj1, Paweł Grygiel2, Marta Anczewska1 and Jacek Wciórka1
Abstract Background: Stigmatisation is a source of chronic stress and a major barrier to recovery for people with mental illnesses. The internalisation of stigma can have a negative impact on an individual’s social relations and lead to feelings of loneliness and depression. Aim: This research is aimed at testing the hypothesis that the internalised stigma of mental illness contributes to the intensification of depressive symptoms indirectly, through its impact on feelings of loneliness. Methods: A total of 110 individuals with diagnoses of psychotic disorders (International Classification of Diseases–10th Revision (ICD-10): F20–F29) were assessed with measures of internalised stigma, loneliness, depression, positive and negative symptoms and global functioning. The ordinary least squares regression was used for data analysis. Results: After adding loneliness to the regression model, the initially significant impact of internalised stigma on depressive symptoms disappeared. As expected, loneliness proved to be a full mediator in the relationship between stigma and depression. Conclusion: The study findings provide useful insights into the mechanisms of the harmful effects of stigma on people with mental illness. Internalised stigma and loneliness should be considered important targets for interventions aiming to promote recovery. Keywords Stigma, loneliness, depression, mental illness
Introduction Stigmatisation is a source of chronic stress and a major barrier to recovery for people with mental illnesses (Corrigan, 2005; van Zelst, 2009). According to Corrigan’s (2005) theoretical model, social stigma consists of three main elements: stereotypes, prejudice and discrimination. Thornicroft, Rose, Kassam and Sartorius (2007) define stigma in a similar way, describing it in terms of problems of knowledge (ignorance), attitudes (prejudice) and behaviour (discrimination). There is a consensus that widespread negative attitudes in society towards people with mental illness (i.e. public stigma) are only one aspect of the problem. No less important are the attitudes and reactions of the stigmatised themselves, who often accept and relate to themselves negative stereotypes of mental illness, which results in lower self-esteem, lack of faith in the efficacy of their own actions and the abandonment of efforts to achieve important life goals (Corrigan, 2005; Corrigan, Larson, & Rüsch, 2009). This phenomenon is referred to as self-stigma or internalised stigma.
Previous studies have shown that internalised stigma of mental illness may contribute to the severity of depressive symptoms (Link, Struening, Rahav, Phelan, & Nuttbrock, 1997; Ritsher & Phelan, 2004; Sibitz, Amering, et al., 2011; Vauth, Kleim, Wirtz, & Corrigan, 2007; Yanos, Roe, Markus, & Lysaker, 2008). However, the exact mechanism of this effect is not well understood. Vauth et al. (2007) proposed a model whereby the effect of self-stigma on depression is mediated by self-efficacy and empowerment. Yanos et al. (2008) have demonstrated that internalised stigma can affect depression through its influence on hope and self-esteem. In this study, we submit to empirical 1I
Department of Psychiatry, Institute of Psychiatry and Neurology, Warsaw, Poland 2Educational Research Institute, Warsaw, Poland Corresponding author: Piotr S’witaj, I Department of Psychiatry, Institute of Psychiatry and Neurology, ul. Sobieskiego 9, 02-957 Warsaw, Poland. Email: [email protected]
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verification yet another possible mechanism of the impact of stigma on depression – through a sense of loneliness. Loneliness can be defined as ‘a situation experienced by the individual as one where there is an unpleasant or inadmissible lack of (quality of) certain relationships’ (De Jong Gierveld, 1987, p. 120). This phenomenon is related, above all, to the failure to satisfy the need for intimacy, and it arises on the basis of the differences between ideal and actually perceived interpersonal relationships. It is basically a subjective experience and, as such, should be distinguished from social isolation, which concerns the objective characteristics of the situation and refers to the absence of relationships with other people (De Jong Gierveld, van Tilburg, & Dykstra, 2006). That is to say, socially isolated persons are not necessarily lonely, and vice versa. Most people at least occasionally experience loneliness (Heinrich & Gullone, 2006), yet individuals with mental illness are among the groups particularly exposed to its severe and persistent forms (Ernst & Cacioppo, 1999; Perese & Wolf, 2005; West, Kellner, & Moore-West, 1986). A study conducted on a representative sample of the population of England showed that all mental disorders were strongly associated with feelings of loneliness, and in the case of people with two or three mental disorders, there was an approximately 20-fold increase in odds of loneliness compared with those with no mental disorder (Meltzer et al., 2013). Stigmatisation is considered to be one of the main reasons for experiencing loneliness among persons with mental illness (Perese & Wolf, 2005). The most obvious manifestation of the effect that stigma has on breaking the individual’s social ties is rejection by others and discrimination in many areas of life (Wahl, 1999). However, people with mental illness might also withdraw themselves from social contacts for fear of rejection (Corrigan et al., 2009; Link, Cullen, Struening, Shrout, & Dohrenwend, 1989). It has been found that self-stigma may affect various aspects of the social integration of people receiving psychiatric treatment, such as social networks and interpersonal relationships (Link et al., 1989; Lysaker, Davis, Warman, Strasburger, & Beattie, 2007; Perlick et al., 2001) or the sense of belonging in the community (Prince & Prince, 2002). Nonetheless, we are not familiar with any empirical study that directly assessed the impact of internalised stigma of mental illness on the feelings of loneliness. A review of studies regarding the relationship between loneliness and depression has shown that these two are in fact separate yet closely related phenomena (Cacioppo & Hawkley, 2009; Heinrich & Gullone, 2006). The results of some longitudinal studies carried out on non-clinical populations suggest that while loneliness and depression are mutually dependent in time, the impact of the sense of loneliness on depressive symptoms is greater (Vanhalst, Klimstra, et al., 2012) and more stable (Vanhalst, Luyckx,
Teppers, & Goossens, 2012) than that of depression on loneliness. It follows that stigmatisation can lead to loneliness, which in turn is recognised as a predictor of depression. The aim of this study is to test the hypothesis that loneliness is a full mediator in the relationship between internalised stigma and depression among people with psychotic disorders.
Method Participants A convenience sample of psychiatric patients was recruited from several mental health-care facilities in Warsaw (Poland). The inclusion criteria were as follows: (1) diagnosis of non-affective psychotic disorder (International Classification of Diseases–10th Revision (ICD-10): F20– F29); (2) age over 18 years; (3) written, informed consent to participate in the study; and (4) a stable mental state, according to the attending psychiatrist, good enough to understand the questions and complete the set of questionnaires accurately. Patients with active drug or alcohol dependence, organic brain disease, severe cognitive deficits or documented mental retardation were excluded. Altogether, the study included 110 patients. Table 1 presents the socio-demographic and clinical characteristics of the sample.
Measures Self-stigma was assessed with the aid of the Internalised Stigma of Mental Illness (ISMI) scale (Ritsher, Otilingam, & Grajales, 2003). This is a self-report questionnaire consisting of 29 items, grouped into five sub-scales: alienation, stereotype endorsement, discrimination experience, social withdrawal and stigma resistance. Answers to the ISMI statements are given on a 4-point scale from 1 (definitely disagree) to 4 (definitely agree). A global score is calculated by summing up the ratings of individual items and then dividing the total by the number of items. A higher score stands for higher stigma. As it has been shown that the stigma resistance sub-scale has weaker psychometric properties than the other four sub-scales (Ritsher et al., 2003), and it measures a separate theoretical construct (Sibitz, Unger, Woppmann, Zidek, & Amering, 2011), in this study, it was not included in the total scale score. In our sample, Cronbach’s α for the ISMI was found to be .94. Loneliness was measured by a short version of the De Jong Gierveld Loneliness Scale (DJGLS; De Jong Gierveld & Kamphuis, 1985; De Jong Gierveld & van Tilburg, 2006). This instrument consists of six items, to which the interviewees respond using a 5-point scale ranging from 1 (strongly agree) to 5 (strongly disagree). It can be used to assess both the overall level of loneliness and two of its
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Table 1. Socio-demographic and clinical characteristics of the participants (N = 110). Characteristic Sex Men Women Age (years) Living situation Alone With family of origin With own family With others Education Secondary or lower Higher Place of residence Village or small town (50,000 residents) Employment status Employed Not employed Diagnosis (ICD-10 code) Schizophrenia (F20) Schizotypal disorder (F21) Persistent delusional disorder (F22) Acute psychotic disorder (F23) Induced delusional disorder (F24) Schizoaffective disorder (F25) Other nonorganic psychotic disorder (F28) Type of psychiatric facility Inpatient ward Day ward Community mental health centre Outpatient clinic Duration of illness (years) Number of psychiatric inpatient hospitalisations
n (%)/mean (SD) 43 (39.1%) 67 (60.9%) 38.4 (11.4) 25 (22.7) 62 (56.4) 18 (16.4) 5 (4.5) 71 (64.5) 39 (35.5) 25 (22.7) 85 (77.3) 28 (25.5) 82 (74.5) 93 (84.5) 2 (1.8) 4 (3.6) 3 (2.7) 1 (0.9) 6 (5.5) 1 (0.9)
33 (30.0) 72 (65.5) 3 (2.7) 2 (1.8) 12.4 (10.5) 4.9 (4.9)
SD: standard deviation; ICD-10: International Classification of Diseases–10th Revision.
dimensions: emotional (3 items) and social (3 items). After recoding the three items referring to the emotional aspects of loneliness, a higher total score indicates a more intense global sense of loneliness. Cronbach’s α for the DJGLS in this study was .83. The intensity of depressive symptoms was evaluated by means of the Calgary Depression Scale for Schizophrenia (CDSS; Addington, Addington, & Schissel, 1990). The scale includes nine items which are rated by a clinician on a scale from 0 (absence of a symptom) to 3 (severe symptom). In this study, the value of Cronbach’s α for the CDSS was .82.
The overall functioning of the participants was measured with the use of the Global Assessment of Functioning (GAF) Scale (American Psychiatric Association, 1994). The GAF takes into account three aspects of functioning: psychological, interpersonal and occupational. The assessment is made by a clinician on a scale ranging from 1 (the worst possible functioning) to 100 (the best possible functioning). In this study, it was the highest level of functioning in the past year that was evaluated. The severity of psychopathological symptoms was assessed using the standard version of the Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1988). This instrument comprises 18 items scored by a clinician on a scale which ranges from 1 (symptom not present) to 7 (symptom extremely severe). Two out of five BPRS subscales, differentiated by Shafer (2005) on the basis of a meta-analysis of factor analyses of the scale, have been selected for the purposes of this study: positive symptoms (unusual thought content, conceptual disorganisation, hallucinatory behaviour and grandiosity) and negative symptoms (blunted affect, emotional withdrawal and motor retardation). In the current sample, the values of Cronbach’s α for the sub-scales of positive and negative symptoms were .60 and .74, respectively. Means and standard deviations for the instruments used in the study are presented in Table 2.
Procedures The data used in this article are part of a larger project aimed at the analysis of the factors that have an impact on the recovery of persons with mental illness. The study was approved by the Bioethical Committee at the Institute of Psychiatry and Neurology (IPiN) in Warsaw. In each participating service, eligible patients were identified by staff psychiatrists. They were then approached by the members of the research team, who invited them to take part in the study. All participants provided their informed consent. Socio-demographic and clinical data were collected on the basis of information obtained from the patients and analysis of available medical records. Self-report questionnaires (ISMI, DJGLS) were filled out by the respondents – depending on preference – in private or in the presence (and, if necessary, with the help) of the researcher. The CDSS, GAF and BPRS were completed by trained psychologists and psychiatrists.
Data analysis Descriptive statistics. Means and standard deviations or percentages, as appropriate, for all study variables, Cronbach’s α coefficients for the instruments used, and Pearson product–moment correlations between the key variables were calculated by means of IBM SPSS Statistics version 21 (SPSS Inc., Chicago, IL).
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Table 2. Means and standard deviations (SDs) for the instruments used in the study (N = 110). Instrument
Mean (SD)
ISMIa DJGLSb CDSSc GAFd Positive symptoms sub-scale of the BPRSe Negative symptoms sub-scale of the BPRSf
2.39 (0.53) 17.13 (5.14) 5.81 (4.47) 54.57 (14.84) 7.84 (3.64) 8.26 (3.41)
ISMI: Internalised Stigma of Mental Illness; DJGLS: De Jong Gierveld Loneliness Scale; CDSS: Calgary Depression Scale for Schizophrenia; GAF: Global Assessment of Functioning; BPRS: Brief Psychiatric Rating Scale. aPossible scores range from 1 to 4, with higher scores indicating more severe stigma. bPossible scores range from 6 to 30, with higher scores indicating more severe sense of loneliness. cPossible scores range from 0 to 27, with higher scores indicating more severe depressive symptoms. dPossible scores range from 1 to 100, with higher scores indicating better psychosocial functioning. ePossible scores range from 4 to 28, with higher scores indicating more severe positive symptoms. fPossible scores range from 3 to 21, with higher scores indicating more severe negative symptoms.
Figure 1. Schematic model with loneliness as the mediator in the relationship between internalised stigma and depression.
IV: independent variable (predictor); DV: dependent variable; MV: mediator variable. Path c represents the total effect of internalised stigma on depression (without considering the mediating effect of loneliness). Path a refers to the direct impact of internalised stigma on loneliness. Path b depicts the direct impact of loneliness on depression after controlling for internalised stigma. Path c′ represents the direct impact of internalised stigma on depression after controlling for loneliness. The indirect effect of internalised stigma on depression via loneliness is calculated as the product of the direct effects of internalised stigma on loneliness and loneliness on depression (a × b).
Mediation analysis. According to Baron and Kenny (1986), a mediating relationship exists if (1) the independent variable (IV) predicts the presumed mediator variable (MV); (2) the MV predicts the dependent variable (DV), controlling for the IV; (3) after controlling for the effects of the MV, a previously significant relationship between the IV and the DV becomes non-significant (full or perfect mediation) or weaker (partial mediation). Thus, following the procedure proposed by Baron and Kenny, the analyses of the role of loneliness in mediating the relationship between internalised stigma and depression were planned in several stages (see Figure 1). The starting point was to verify the significance of the relationship between internalised stigma and depression,
without considering the mediating effect of loneliness (path c). In the next step, the impact of stigma on loneliness was assessed (path a). In the final model, we tested the influence of loneliness on depression, controlling for the effects of stigma (path b), and the influence of stigma on depression, controlling for loneliness (path c′). In all analyses conducted, the following socio-demographic and clinical background characteristics were used as covariates: sex, age, place of residence, level of education, living situation, employment status, duration of illness, type of psychiatric facility, number of psychiatric inpatient hospitalisations, the level of psychosocial functioning assessed by the GAF scale and the severity of positive and negative symptoms measured by the BPRS sub-scales. The hypothesised mediation model was analysed using the PROCESS macro for SPSS (Hayes, 2013), based on ordinary least squares (OLS) regression. The bootstrapping procedure developed by Preacher and Hayes (2008) was applied for testing the significance of the indirect effect. Unlike traditional tests, such as the Sobel test (Sobel, 1982), bootstrapping does not require the assumption of a normal distribution of the indirect effect, difficult to meet especially for small research samples. We used 50,000 bootstrap resamples to calculate the bias-corrected 95% confidence interval (CI). If the interval does not include zero, the effect is statistically significant at p < .05.
Results Correlations between key study variables are presented in Table 3. As expected, internalised stigma, loneliness and depression were all significantly positively correlated with each other. Table 4 shows the results of the regression analyses testing the mediating effect of loneliness on the relationship between internalised stigma and depression.
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Table 3. Pearson correlations between internalised stigma, loneliness, depression, positive and negative symptoms and global functioning (N = 110). Variable
1
1. ISMI 2. DJGLS 3. CDSS 4. GAF 5. Positive symptoms (BPRS) 6. Negative symptoms (BPRS)
–
2
.44** .32** −.09 −.09 .11
3
4
5
6
– .36** −.07 .02 .03
– −.21* .01 .11
– −.46** −.54**
– .39**
–
ISMI: Internalised Stigma of Mental Illness; DJGLS: De Jong Gierveld Loneliness Scale; CDSS: Calgary Depression Scale for Schizophrenia; GAF: Global Assessment of Functioning; BPRS: Brief Psychiatric Rating Scale. *p < .05, **p < .01.
The unstandardised regression coefficient for path c turned out to be statistically significant: t(97) = 2.44, p < .05. The positive value of the coefficient (B = 2.41, standard error (SE) = .99) indicates that as the level of internalised stigma increases – with socio-demographic and clinical variables controlled – the level of depression also grows. The unstandardised regression coefficient for path a was also positive (B = 3.72, SE = 1.15) and significant: t(97) = 3.23, p < .01. This means that a more intense internalised stigma is associated with a higher sense of loneliness. The regression coefficient for path b was significantly different from zero as well: t(96) = 3.05, p < .01. Its positive value (B = .27, SE = .09) indicates that as the sense of loneliness grows, so does the intensity of depressive symptoms. What is important in the context of our hypotheses is that the direct impact of stigma on depression (path c′) proved to be statistically non-significant: t(96) = 1.35, p = .18. When both stigma and loneliness were introduced to the regression equation, the effect of loneliness remained significant, but the effect of stigma did not. At the same time, the bias-corrected bootstrap 95% CI did not contain zero (.29, 2.14), showing that the indirect impact of internalised stigma on depression through loneliness (B = 1.01, SE = .47) was statistically significant. Taken together, these findings support the full mediation hypothesis.
Discussion In this study, we have analysed the associations between internalised stigma, loneliness and depression among a sample of patients with psychotic disorders. We found support for the hypothesis that even after controlling for sociodemographic and clinical background characteristics, self-stigma contributes to depressive symptoms, with this effect being fully mediated by feelings of loneliness. While the link between stigma and depression was consistently identified in the literature (Link et al., 1997; Ritsher & Phelan, 2004; Sibitz, Amering, et al., 2011; Vauth et al., 2007; Yanos et al., 2008), our results are a step forward in clarifying the mechanism underlying this relationship.
Previous research demonstrated the role of various selfconcept variables, such as self-efficacy and empowerment (Vauth et al., 2007), or self-esteem and hopefulness (Yanos et al., 2008), in mediating the relationship between selfstigma and the severity of depressive symptoms. This study adds to these findings by showing that internalised stigma may lead to depression not only by changing the way people perceive and feel about themselves but also by affecting their perception of their social relations. Future studies should explore the mutual relationships between loneliness and various aspects of self-concept in the process of stigmatisation. The results of this research have important implications for clinical practice. They indicate that internalised stigma may impede the process of recovery of people with mental illness and therefore needs to be addressed in the therapeutic programmes. A review of empirical studies of self-stigma reduction strategies identified two prominent approaches in this area: interventions directed at correcting the stigmatising beliefs and attitudes of the individual and interventions attempting to enhance the individual’s skills for coping with self-stigma through improvements in self-esteem, empowerment and help-seeking behaviour (Mittal, Sullivan, Chekuri, Allee, & Corrigan, 2012). Our study suggests that counteracting the harmful effects of self-stigmatisation should also involve interventions aimed at reducing the individual’s feelings of loneliness. Researchers distinguish four primary strategies of loneliness reduction interventions: improving social skills, enhancing social support, increasing opportunities for social contact and addressing maladaptive social cognition (Masi, Chen, Hawkley, & Cacioppo, 2011). Although some evidence exists that the most successful strategy is addressing deficits in social cognition (Masi et al., 2011), in practice, the selection of appropriate interventions for people with severe mental illness should be made after careful consideration of such factors as the person’s residual disabilities and existing social network, the characteristics of the interventions, their effectiveness, the likelihood of a good fit between the person and the intervention, and the availability of interventions in the community (Perese & Wolf, 2005).
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0.99 – 1.18 0.06 1.20 1.08 1.14 1.24 0.06 0.94 0.09 0.04 0.16 0.20 4.60
2.41* – −0.79 −0.02 −0.36 −1.43 0.48 0.95 −0.00 −0.22 −0.12 −0.06 0.01 −0.09 5.06 0.19 1.70*
SE
−0.11 −0.05 0.01 −0.08 2.10 0.26 2.18*
0.01 0.07
1.46
1.00
−0.96
1.40 0.27** −0.87 −0.04 −0.37
B
0.09 0.04 0.16 0.19 4.56
0.06 0.88
1.20
1.06
1.00
1.03 0.09 1.21 0.06 1.21
SE
path c′ and path b
path c B
Direct effects of stigma on depression and loneliness on depression
Total effect of stigma on depression
0.31 0.10 0.02
3.72**
−0.03 −0.03 0.03 −0.03 10.90 0.27 3.84**
−0.03 −1.07
−1.90
−1.90
−1.74
–
B
path a
–
0.12 0.04 0.20 0.20 5.60
0.08 1.33
1.28
1.32
1.21
1.20 0.07 1.22
1.15
SE
Direct effect of stigma on loneliness
1.01*
B
0.47
SE
path a × b
0.29
Lower
2.14
Upper
CI for indirect effect
Indirect effect of stigma on depression
SE: standard error; CI: confidence interval; ISMI: Internalised Stigma of Mental Illness, DJGLS: De Jong Gierveld Loneliness Scale; GAF: Global Assessment of Functioning; BPRS: Brief Psychiatric Rating Scale. *p < .05, **p < .01.
Internalised stigma (ISMI) Loneliness (DJGLS) Covariates Sex (0 – women, 1 – men) Age Place of residence (0 – village or small town < 50,000 residents, 1 – town above 50,000 residents) Education (0 – secondary or lower, 1 – higher) Living situation (0 – living alone, 1 – living with someone) Employment (0 – employed, 1 – not employed) Duration of illness Psychiatric facility (0 – inpatient ward, 1 – other) Number of inpatient hospitalisations Global functioning (GAF) BPRS positive symptoms BPRS negative symptoms Constant R2 F
Variable
Table 4. Results of the regression analyses testing the mediating effect of loneliness on the relationship between internalised stigma and depression (N = 110).
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A few methodological limitations of this study need to be recognised. First, the cross-sectional nature of the data makes it impossible to draw definitive conclusions about the direction of the relationships found. We cannot rule out the possibility that depression leads to an increase in both loneliness and self-stigma; therefore, it is necessary to verify our results in studies with a longitudinal design. Furthermore, we used a relatively small convenience sample, which may not be representative of the entire population of people with mental illness in Poland. We should also mention the limitations imposed by the method of measurement of internalised stigma. Although the ISMI is one of the most frequently used (Livingston & Boyd, 2010) and one of the highest rated in terms of its psychometric properties (Brohan, Slade, Clement, & Thornicroft, 2010), measures of the subjective experience of the stigma of mental illness, the reliability and validity of its Polish version have not yet been systematically studied. Besides, this instrument does not assess the implicit aspects of self-stigma, which may also be clinically significant (Rüsch, Corrigan, Todd, & Bodenhausen, 2010). It is also worth noting that our analysis has taken into account only a generalised sense of loneliness. It seems possible that internalised stigma and depression are differentially associated with various dimensions of loneliness (e.g. social and emotional loneliness) and/or forms of loneliness experienced in different relationships (e.g. with friends, family members or romantic partners) – this needs to be explored in future studies, using multidimensional measures of loneliness, such as, for example, the Social and Emotional Loneliness Scale for Adults (SELSA; DiTommaso & Spinner, 1993). Finally, it cannot be excluded that some unmeasured variables account for the associations we observed. In conclusion, our study provides useful insights into the mechanisms of the harmful effects of stigma on people receiving psychiatric treatment. The results obtained support the view that self-stigmatising attitudes increase an individual’s sense of loneliness, which is a crucial marker of social relationship deficits (Heinrich & Gullone, 2006), thus contributing to the development of depressive symptoms. Internalised stigma and loneliness should be considered important targets for interventions aiming to promote recovery from mental illness. Acknowledgements We wish to express our thanks to the following colleagues for their help in recruiting patients and collecting the data: Joanna Krzyżanowska, Aleksandra Kur, Monika Lis-Szymczak, Alicja Multarzyńska, Magdalena Musiałowicz-Paterek, Urszula OlbryśBańkowska, Dorota Parnowska, Katarzyna Romanowicz, Izabela Stefaniak, Ewa Winkler, Tomasz Grzegorczyk and Sławomir Pietrak. We also thank two anonymous reviewers for their constructive comments on an earlier version of this article.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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