Relation between Internalized Stigma and its correlates among Psychiatric Inpatients in Minia Governorate

Introduction:

Psychological disorders are often used interchangeably with the terms of mental disorders, psychiatric disorders, or mental illness, the “formal” term is mental disorders which was defined in the last edition of the American Psychiatric Association's diagnostic manual (the DSM-5) as: "a syndrome that is characterized by clinically significant disturbances in an individual's cognition, emotion regulation or behavior that reflect a dysfunction in the psychological, biological or developmental process underlying mental functioning (American Psychiatric Association APA, 2013). Mental illnesses are prevalent worldwide and in Egypt. The global prevalence of common mental disorders is approximately 1 in 5 adults (17.6%) (Steel et al., 2014). A recent World Health Organization (WHO) meta-analysis estimated that the prevalence of mental disorders was 22.1% in emergency settings (Charlson et al., 2019). In Egypt, the National Survey of Mental Disorders estimated overall prevalence as 16.93% of the studied adult population (Ebrahim et al., 2020).

Unfortunately, it is observed that once individuals are referred to a psychiatrist and are diagnosed with a mental disorder, they feel stigmatized and according to prevailing theories, some of these stigmatized individuals internalize and apply these negative attitudes and stereotypes to themselves, resulting in what has been defined as “self-stigma (Schwarzbold et al., 2021). According to Corrigan & Rao (2012), self-stigma develops in progressive stages: Individuals become aware of public stigma, agree with negative stereotypes, and apply these stereotypes to themselves resulting in poorer self-esteem and self-efficacy
(Hofer et al., 2019).

Internalized stigma, or self-stigma, has been defined as “shame, evaluative thoughts, and fear of enacted stigma that results from individuals’ identification with a stigmatized group” (Olçun & Altun, 2017 and Yılmaz & Okanlı, 2015). Also, Corrigan & Rao. (2012) added that,the process of internalized stigma includes the repeated occurrence of negative emotions and thoughts about the stigma and the fact that such thoughts come automatically and involuntarily. In this respect, Sen. (2018) clarified that, stigma arises when insufficient or incomplete knowledge supports negative stereotypes regarding a marginalized population – facilitating discrimination and exclusion. For instance, stigma can be derived from the belief that people with mental illness are responsible for their illness, incompetent, violent, and weak in character and therefore should be socially restricted
(Eksteen et al., 2017).

Furthermore, self-stigma has been associated with poorer treatment adherence (Kamaradova et al., 2016 and Yilmaz & Okanlı, 2015) and with negative outcomes, including reductions in self-esteem (Hofer et al., 2016 and Picco et al., 2016), hope (Berry & Greenwood, 2018), quality of life (Lien et al., 2018 and Picco et al., 2016). Internalized stigma is prevalent among individuals with serious mental illness and can have a negative impact on self-concept, social relationships, community involvement, psychiatric health, and well-being and may impede the recovery process for individuals with mental illness as concluded by Drapalski et al., (2013).

To date, the correlation between internalized stigma and sociodemographic as well as clinical variables remains unclear, and there are few studies exploring such correlations, especially in developing countries. Understanding the internalized stigma and how it correlates to sociodemographic (age, gender, education, etc.), and clinical health related factors (diagnosis, disease duration, etc.) may help in informing interventions to reduce it among psychiatric patients. (Szcześniak et al., 2018 and Howland et al., 2016).

Regarding sociodemographic variables, the lack of consistency across disparate studies indicates that mentally ill people with a wide range of characteristics are susceptible to internalized stigma. The association of gender, education, and other demographic variables with the ISMI scale scores were not reported in the original English version. Also, in the Japanese version, the study concluded no significant differences in the association between the total ISMI scale score and demographic variables (Tanabe et al., 2016).

Concerning clinical variables, some studies confirm an association between the number of hospital admissions and internalized stigma (Vrbova et al., 2016), whereas others contradict this finding and show no such relation (Holubova et al., 2016). As regard tothe duration of the disease the same author documented that the degree of internalized stigma is lower in patients with unipolar affective disorder compared with patients with psychotic disorders (PDs). On the contrary, Kamaradova et al., 2016 showed thatthe duration of the disease has’t not been confirmed to be linked with internalized stigma and the influence of the type of clinical diagnosis is also unestablished Holubova et al., 2016.

Significance of the study

Several studies in different countries showed that around 80 to 90 percent of patients with mental illness may experience stigma and discrimination; these rates of internalized stigma differ across samples from moderate to severe (Tesfaye et al., 2020). In a study conducted in “Singapore” among psychiatric outpatients, there were, 43.6% of patients experienced moderate to a high level of internalized stigma (Picco et al., 2016) and in a Chinese study, it was reported that 38.3% of Hong Kong and 49.5% of Guangzhou patients were having self-stigma (Young & Ng., 2016).Furthermore, in a descriptive study conducted in Minia governorate, Upper Egypt by (Omer et al., 2016), the results revealed that more than half (53.6%) of the studied patients had a higher level of internalized stigma.

Aim of the study

This study aimed to:

1-        Assess levels of internalized stigma among psychiatric inpatients at Minia governorate.

2-       Investigate relation between sociodemographic, clinical data, and internalized stigma among psychiatric inpatients in Minia governorate.

Subjects and Methods

Research design:

A descriptive correlational research design was utilized in this study.

Setting

This study was conducted at the New Minia Mental Health and Addiction Treatment Hospital in New Minia City which is affiliated to the Ministry of Health. The hospital involves two floors; the outpatient clinics, the pharmacy and the female inpatient unit are on the first floor. The second floor includes the administration office, the department of substance use treatment, male psychiatric inpatient units, and the nursing office. The capacity of this hospital is 53 beds for both sexes which serves the whole Minia governorate.

Subjects:                                                           

A convenience sample of 50 psychiatric inpatients was included in the study.

Inclusion Criteria:

• Both genders.
• Patients’ age ranges from 18 to 55 years.
• Patients who can communicate and interact effectively.

Exclusion criteria

• Mental retardation) intellectual disability (.
• Comorbid diagnosis of substance dependence.
• Acute stage of psychosis.

Tools of Data Collection:

Two tools were utilized in this study:

 Tool (1) Sociodemographic and clinical data questionnaire:

It was developed by the researcher to assess patients’ demographic and clinical data which cover the following items: age, gender, residence, educational level, marital status, occupation, diagnosis, duration of illness, as well as date and type of admission.

Tool (2) Internalized Stigma of Mental Illness Scale (ISMIS):

This scale was developed by Ritsher et al., (2003) which includes 29 items that asses internalized stigma. It consists of five subscales that include: alienation (items 1, 5, 8, 16, 17 and 21), stereotype endorsement (items 2, 6, 10, 18, 19, 23 and 29), discrimination experience (items 3, 15, 22, 25 and 28), social withdrawal (items 4, 9, 11, 12, 13 and 20) and stigma resistance (items 7, 14, 24, 26 and 27). The items are rated by using a 4-point Likert type scale ranged from (1=strongly disagree to 4=strongly agree). The items of the “stigma resistance” subscale are scored in reverse. The total ISMIS score was obtained by adding the scores of five subscales ranging from 29 to 116 points. The higher scores in the ISMI mean that the internalized stigmatization of the person is more severe in the negative sense and the lower scores mean the higher stigma resistance.

Validity: The content validity of the study used scale was tested by five psychiatric and mental health nursing experts. Based on the experts’ comments and recommendations, modifications were done.

Reliability: The reliability of the tools was done by the statistician and revised by the supervisors. The internal consistency of the study scale was calculated using Cronbach's alpha coefficients test, it was0.92 which meant that it was highly reliable.

Pilot study

A pilot study (10%) of the total number that equal to 5 patients of the studied patients was performed to test the research process and determine the feasibility and reliability of the tools used in the study. It also helped in the assessment of the necessary time to fill the tools.

Field work

The purpose of the study was explained by the researcher through direct personal communication with the studied patients for getting their approval and voluntary participation. The researcher went to the hospital two days/ week (Saturday, and Monday,) from 9 to 1 p.m.

Administrative Design:

An official permission was approved from the director of the New Minia hospital for Mental Health and Addiction Treatment at Minia city to conduct the study. Oral and written agreements for patients’ participation in the study were obtained from the studied patients themselves and the patient ethical committee in the hospital.

Ethical Considerations:

A written initial approval obtained from the Research Ethical Committee of the Faculty of Nursing, Minia University, the study follows common ethical participation in clinical research, there is no risk for study subjects during application of this research, and privacy was provided during data collection. Anonymity and confidentiality were assured through coding the data.

Statistical Analysis

Recorded data were analyzed using the statistical package for social sciences; version 26.0 Quantitative data were expressed as mean± standard deviation (SD). Qualitative data were expressed as frequency and percentage. Also, Pearson correlation was used.

Results

Table (1): Frequency distribution of the studied psychiatric patients according to their sociodemographic data (N= 50).

Table (1) shows that, 60 % of patients were males, 38% of them were in the age group “more than 38 years old”, had preparatory school and they were unemployed/housewife. Also, 40% were single and the majority of them live in rural areas (76%).

Table (2): Frequency distribution of the studied psychiatric patients according to their clinical data (N= 50).

Table (2) reflects that 30 % of patients had schizophrenia, more than half (56 %) of them had the disease for more than three years. Meanwhile about three quarters of them (76%) had been hospitalized less than one month. Regarding mode of admission, it was found that 62% of them were admitted voluntarily.

Table (3): Frequency distribution of the studied psychiatric patients’ responses to internalized stigma (ISMI) at Pretest (n= 50).

Notes: ISMS= Internalized Stigma of Mental Illness Scale.

        Table (3) demonstrates that, (66%) of patients are strongly agree that “they are disappointed in themselves for having mental illness”, more than half (54%) were strongly disagreed that they can’t contribute anything to society because they have a mental illness, while less than half (40%, 34%, 34 and 34%) were strongly agreed that mentally ill people tend to be violent, shouldn’t get married, people can tell that they have a mental illness by the way they look and stereotypes about the mentally ill apply to them respectively.

The same table illustrates that more than half (56%) of them were strongly agreed that people ignore them or take them less seriously just because they have a mental illness, more than two thirds 62% were strongly agreed that negative stereotypes about mental illness keep them isolated from the “normal” world. Meanwhile, nearly two thirds (62%, and 60%) were strongly disagreed that they could live their life the way they want to and people with mental illness make important contributions to society.

Figure (1): Frequency distribution of internalized stigma levels among the studied psychiatric patients (N= 50).

Figure (1): clarifies that, (60%) of the patients had a moderate level of internalized stigma, about one quarter (26%) of them had a high level of internalized stigma and 14% have a low level of internalized stigma.

Table (4):Frequency distributions of ISMI subscales levels among the studied psychiatric patients (N= 50).

Table (4): clarifies that, according to frequency distributions of ISMI subscales’ levels, the highest mean score was related to stereotyping and social withdrawal subscales followed by alienation subscale.

Table (5): Relationship between the studied psychiatric patients’ levels of internalized stigma and their scio-demographic data

Table (5): shows that, there were no statistically significant differences between internalized stigma levels and all sociodemographic data of the patients except regarding occupation at (p-value = 0.024).

Table (6): Relationship between the studied psychiatric patients’ levels of internalized stigma and their clinical data.

Table (6): clarifies relationship between the studied psychiatric patients’ levels of internalized stigma and their clinical data. It was found that, there were no statistically significant differences between internalized stigma levels and all clinical data of the patients except regarding duration of patients’ hospitalization (p-value = 0.025).