Internalized stigma among patients with schizophrenia in Ethiopia: a cross-sectional facility-based study

BMC Psychiatry

Abebaw Fekadu¹  Laura Asher⁴  Teshome Shibre³  Dereje Assefa² 

[1] King’s College London, Institute of Psychiatry, Department of Psychological Medicine, London, UK;Amanuel Specialized Mental Hospital, Addis Ababa, Ethiopia;Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia;Department of Epidemiology and Public Health, University College London, London, UK

关键词: Ethiopia;    Recovery;    Adherence;    Schizophrenia;    Internalized stigma;   

Others  :  1124193
DOI  :  10.1186/1471-244X-12-239

 received in 2012-05-28, accepted in 2012-12-27,  发布年份 2012

【 摘 要 】

Background

Despite the potential impact on treatment adherence and recovery, there is a dearth of data on the extent and correlates of internalized stigma in patients with schizophrenia in low income countries. We conducted a study to determine the extent, domains and correlates of internalized stigma amongst outpatients with schizophrenia in Ethiopia.

Methods

The study was a cross-sectional facility-based survey conducted at a specialist psychiatric hospital in Addis Ababa, Ethiopia. Consecutive consenting individuals with a diagnosis of schizophrenia were recruited and assessed using an Amharic version of the Internalized Stigma of Mental Illness (ISMI) scale.

Results

Data were collected from 212 individuals, who were mostly single (71.2%), unemployed (70.3%) and male (65.1%). Nearly all participants (97.4%) expressed agreement to at least one stigma item contained in the ISMI; 46.7% had a moderate to high mean stigma score. Rural residence (OR = 5.67; 95% CI = 2.30, 13.00; p < 0.001), single marital status (OR = 3.39; 95% CI = 1.40, 8.22; p = 0.019) and having prominent psychotic symptoms (OR = 2.33; 95% CI = 1.17, 4.61; p = 0.016) were associated independently with a higher stigma score. Almost half of those who discontinued their treatment reported that they had done so because of perceived stigma. Those who had attempted suicide (45.3%) were more likely to have a high stigma score (OR = 2.29; 95% CI = 1.27, 4.11; p = 0.006). Over 60% of the variation in the experience of stigma was explained by four factors: social withdrawal (16.7%), perceived discrimination (14.1%), alienation (13.9%) and stereotype endorsement (12.7%).

Conclusion

Internalized stigma is a major problem among persons with schizophrenia in this outpatient setting in Ethiopia. Internalized stigma has the potential to substantially affect adherence to medication and is likely to affect the recovery process.

【 授权许可】

   
2012 Assefa et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Torrey EF: Surviving Schizophrenia: A manual for Families, Consumers and Providers. 3rd edition. New York: Harper and Row; 1995.
• [2]Thornicroft G, Rose D, Kassam A, Sartorius N: Stigma: ignorance, prejudice or discrimination? Brit J Psychiat 2007, 190:192-193.
• [3]Brohan E, Slade M, Clement S, Thornicroft G: Experiences of mental illness stigma, prejudice and discrimination: a review of measures. BMC Health Serv Res 2010, 10:80. BioMed Central Full Text
• [4]Yanos PT, Roe D, Markus K, Lysaker PH: Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatr Serv 2008, 59:1437-1442.
• [5]Link BG, Struening EL, Neese-Todd S, Asmussen S, Phelan JC: Stigma as a barrier to recovery: the consequences of stigma for the self-esteem of people with mental illnesses. Psychiatr Serv 2001, 52:1621-1626.
• [6]Link BG, Struening EL, Rahav M, Phelan JC, Nuttbrock L: On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. J Health Soc Behav 1997, 38:177-190.
• [7]Vauth R, Kleim B, Wirtz M, Corrigan PW: Self-efficacy and empowerment as outcomes of self-stigmatizing and coping in schizophrenia. Psychiatr Res 2007, 150:71-80.
• [8]Perlick DA, Rosenheck RA, Clarkin JF, Sirey JA, Salahi J, Struening EL, Link BG: Stigma as a barrier to recovery: adverse effects of perceived stigma on social adaptation of persons diagnosed with bipolar affective disorder. Psychiatr Serv 2001, 52:1627-1632.
• [9]Ritsher JB, Phelan JC: Internalized stigma predicts erosion of morale among psychiatric outpatients. Psychiatr Res 2004, 129(3):257-265.
• [10]Sirey JA, Bruce ML, Alexopoulos GS, Perlick DA, Friedmann SJ, Meyers BS: Perceived stigma and patient-rated severity of illness as predictors of antidepressant drug adherence. Psychiatr Serv 2001, 52:1615-1620.
• [11]Sirey JA, Bruce ML, Alexopoulos GS, Perlick DA, Raue P, Friedmann SJ, Meyers BS: Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. Am J Psychiat 2001, 158:479-481.
• [12]Wu H-C, Tang I-C: Quality of life and self-stigma in individuals with schizohprenia. Psychiat Quart 2012. In press
• [13]Link BG: Understanding labelling effects in the area of mental disorders: an assessment of the effects of expectations of rejection. Am Sociol Rev 1987, 52:96-112.
• [14]Moriarty A, Jolley S, Callanan MM, Garety P: Understanding reduced activity in psychosis: the roles of stigma and illness appraisals. Soc Psychiatry Psychiatr Epidemiol 2012. In press
• [15]Weiss MG, Jadhav S, Raguram R, Vounatsou P, Littlewood R: Psychiatric stigma across cultures: local validation in Bangalore and London. Anthropol Med 2001, 8:71-87.
• [16]Littlewood R: Cultural variation in the stigmatisation of mental illness. Lancet 1998, 352:1056-1057.
• [17]Cooper JE, Sartorius N: Cultural and temporal variations in schizophrenia: a speculation on the importance of industrialisation. Br J Psychiatry 1977, 130:50-55.
• [18]Yang LH, Kleinman A: Face’ and the embodiment of stigma in China: The cases of schizophrenia and AIDS. Soc Sci Med 2008, 67:398-408.
• [19]Yang LH, Kleinman A, Link BG, Phelan JC, Lee S, Good B: Culture and stigma: Adding moral experience to stigma theory. Soc Sci Med 2007, 64:1524-1535.
• [20]Barke A, Nyarko S, Klecha D: The stigma of mental illness in Southern Ghana: attitudes of the urban population and patients’ views. Soc Psych Psych Epid 2011, 46:1191-1202.
• [21]Adewuya AO, Owoeye AO, Erinfolami AO, Ola BA: Correlates of Self-Stigma Among Outpatients With Mental Illness in Lagos, Nigeria. Int J Soc Psychiatry 2011, 57:418-427.
• [22]Botha U, Koen L, Niehaus D: Perceptions of a South African schizophrenia population with regards to community attitudes towards their illness. Soc Psych Psych Epid 2006, 41:619-623.
• [23]Shibre T, Negash A, Kullgren G, Kebede D, Alem A, Fekadu A, Fekadu D, Medhin G, Jacobsson L: Perception of stigma among family members of individuals with schizophrenia and major affective disorders in rural Ethiopia. Soc Psych Psych Epid 2001, 36:299-303.
• [24]Kebede D, Alem A, Shibre T, Negash A, Fekadu A, Fekadu D, Deyassa N, Jacobsson L, Kullgren G: Onset and clinical course of schizophrenia in Butajira-Ethiopia—a community-based study. Soc Psych Psych Epid 2003, 38:625-631.
• [25]WHO: Mental Health Gap Action Programme (mhGAP): Scaling up care for mental, neurological, and substance use disorders. Geneva: WHO; 2008.
• [26]Henderson C, Thornicroft G: Stigma and discrimination in mental illness: Time to Change. Lancet 2009, 373(9679):1928-1930.
• [27]Ritsher JB, Otilingam PG, Grajales M: Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatr Res 2003, 121:31-49.
• [28]Lysaker PH, Roe D, Yanos PT: Toward Understanding the Insight Paradox: Internalized Stigma Moderates the Association Between Insight and Social Functioning, Hope, and Self-esteem Among People with Schizophrenia Spectrum Disorders. Schizophr Bull 2007, 33(1):192-199.
• [29]Sibitz I, Unger A, Woppmann A, Zidek T, Amering M: Stigma Resistance in Patients With Schizophrenia. Schizophr Bull 2011, 37(2):316-323.
• [30]WHO: The Composite International Diagnostic Interview, version 2.1. Geneva: WHO; 1997.
• [31]APA: The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Washington, DC: APA; 1994.
• [32]Brohan E, Elgie R, Sartorius N, Thornicroft G, GAMIAN-Europe Study Group: Self-stigma, empowerment and perceived discrimination among people with schizophrenia in 14 European countries: The GAMIAN-Europe study. Schizophr Res 2010, 122:232-238.
• [33]Adewuya AO, Owoeye AO, Erinfolami AO, Ola BA: Correlates of Self-Stigma Among Outpatients With Mental Illness in Lagos, Nigeria. Int J Soc Psychiatry 2011, 57(4):418-427.
• [34]Barke A, Nyarko S, Klecha D: The stigma of mental illness in Southern Ghana: attitudes of the urban population and patients’ views. Soc Psychiatry Psychiatr Epidemiol 2011, 46(11):1191-1202.
• [35]Botha U, Koen L, Niehaus D: Perceptions of a South African schizophrenia population with regards to community attitudes towards their illness. Soc Psychiatry Psychiatr Epidemiol 2006, 41(8):619-623.
• [36]Lauber C, Rössler W: Stigma towards people with mental illness in developing countries in Asia. Int Rev Psychiatr 2007, 19:157-178.
• [37]Federal Democratic Republic of Ethiopia Population Census Commission: Summary and statistical report of the 2007 population and housing census, population size by age and sex. Addis Ababa: United Nations Population Fund; 2008.
• [38]Ministry of Finance and Economic Development (MoFED): Ethiopia: 2010 MDGs Report trends and prospects for meeting MDGs by 2015. Addis Ababa: MoFED; 2010.
• [39]Kebede D, Alem A, Shibre T, Deyessa N, Negash A, Beyero T, Medhin G, Fekadu A: Symptomatic and functional outcome of bipolar disorder in Butajira, Ethiopia. J Affect Disord 2006, 90:239-249.
• [40]Fekadu A, Kebede D, Alem A, Fekadu D, Mogga S, Negash A, Medhin G, Beyero T, Shibre T: Clinical outcome in bipolar disorder in a community-based follow-up study in Butajira, Ethiopia. Acta Psychiat Scand 2006, 114:426-434.
• [41]Rosen A: Destigmatizing day-to-day practices: what developed countries can learn from developing countries. World Psychiatry 2006, 5(1):21-24.
• [42]Cohen A, Patel V, Thara R, Gureje O: Questioning an Axiom: Better Prognosis for Schizophrenia in the Developing World? Schizophr Bull 2008, 34:229-244.
• [43]Alem A, Kebede D, Fekadu A, Shibre T, Fekadu D, Beyero T, Medhin G, Negash A, Kullgren G: Clinical Course and Outcome of Schizophrenia in a Predominantly Treatment-Naive Cohort in Rural Ethiopia. Schizophr Bull 2009, 35(3):646-654.
• [44]Fekadu A, Kebede D, Alem A, Fekadu D, Mogga S, Negash A, Medhin G, Beyero T, Shibre T: Clinical outcome in bipolar disorder in a community-based follow-up study in Butajira, Ethiopia. Acta Psychiatr Scand 2006, 114(6):426-434.
• [45]Ritsher JB, Phelan JC: Internalized stigma predicts erosion of morale among psychiatric outpatients. Psychiatry Res 2004, 129(3):257-265.
• [46]Bekele YY, Flisher AJ, Alem A, Baheretebeb Y: Pathways to psychiatric care in Ethiopia. Psychol Med 2009, 39(03):475-483.
• [47]Link BG, Phelan JC: Conceptualizing Stigma. Annu Rev Sociol 2001, 27:363-385.
• [48]Mak WWS, Wu CFM: Cognitive Insight and Causal Attribution in the Development of Self-Stigma Among Individuals With Schizophrenia. Psychiatr Serv 2006, 57:1800-1802.
• [49]Shibre T, Negash A, Kullgren G, Kebede D, Alem A, Fekadu A, Fekadu D, Medhin G, Jacobsson L: Perception of stigma among family members of individuals with schizophrenia and major affective disorders in rural Ethiopia. Soc Psychiatry Psychiatr Epidemiol 2001, 36(6):299-303.
• [50]WHO: mental health Gap Action Programme (mhGAP). Geneva: WHO; 2008.
• [51]Nicholson LA: Rural mental health. APT 2008, 14:302-311.
• [52]Brohan E, Gauci D, Sartorius N, Thornicroft G, for the GAMIAN-Europe Study Group: Self-stigma, empowerment and perceived discrimination among people with bipolar disorder or depression in 13 European countries: The GAMIAN-Europe study. J Affect Disorders 2011, 129:56-63.
• [53]Yen CF, Chen CC, Lee Y, Tang TC, Yen JY, Ko CH: Self-stigma and its correlates among outpatients with depressive disorders. Psychiatr Serv 2005, 56:599-601.
• [54]Werner P, Stein-Shvachman I, Heinik J: Perceptions of self-stigma and its correlates among older adults with depression: a preliminary study. Int Psychogeriatr 2009, 21:1180-1189.
• [55]Livingston JD, Boyd JE: Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis. Soc Sci Med 2010, 71(12):2150-2161.
• [56]Fekadu A, Desta M, Alem A, Prince M: A descriptive analysis of admissions to Amanuel Psychiatric Hospital in Ethiopia. Ethiop J Health Dev 2007, 21:173-178.