- Email: [email protected]
Change in internalized stigma and social functioning among persons diagnosed with severe mental illness
Psychiatry Research 200 (2012) 1032–1034
Contents lists available at SciVerse ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Brief report
Change in internalized stigma and social functioning among persons diagnosed with severe mental illness Philip Theodore Yanos a,n, Michelle Leigh West a, Lauren Gonzales a, Stephen Mark Smith a, David Roe b, Paul Henry Lysaker c a
John Jay College of Criminal Justice, City University of New York, NY, USA Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel c Indiana University School of Medicine, Department of Psychiatry, Indianapolis, IN, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 23 November 2011 Received in revised form 18 April 2012 Accepted 13 June 2012
This study examined the relationship between change in internalized stigma and social functioning over time. Thirty-five individuals with severe mental illness completed measures of self-stigma, social functioning and symptoms at baseline, 4 months, and 7 months. Change in self-stigma was significantly negatively related to change in social functioning, controlling for negative symptoms. & 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Self-stigma Social functioning Negative symptoms
1. Introduction An accumulating body of evidence supports that internalized stigma, or self-stigma, is associated with compromised outcomes related to recovery from severe mental illness (Yanos et al., 2010a). In a meta-analysis of 45 studies, Livingston and Boyd (2010) found moderate to strong inverse relationships between self-stigma and self-esteem, hope, self-efficacy, social support, and subjective quality of life. A noted limitation of many of the reviewed studies, however, was that they almost exclusively employed cross-sectional designs. In addition, despite its central role in most definitions of recovery, social functioning (which includes vocational functioning and frequency of social contacts) has been rarely examined in relation to self-stigma (and thus was not included in Livingston and Boyd’s review). In their conceptual model of how self-stigma affects recovery, Yanos et al. (2010a) hypothesized that internalized stigma would compromise social functioning by leading to poorer vocational outcomes and increased social isolation. Similarly, Corrigan et al. (2009) hypothesized that self-stigma results in a ‘‘why try’’ effect which negatively impacts the pursuit of life goals. To date, three studies support that self-stigma is negatively ˜oz related to social functioning. In two cross-sectional studies, Mun et al. (2011) found a moderate relationship between internalized
n
Correspondance to: John Jay College of Criminal Justice, City University of New York, Psychology Department, 524 West 59th Street, NY 10019, USA. Tel.: þ 212 237 8773; fax: þ 212 237 8930. E-mail address: [email protected] (P.T. Yanos). 0165-1781/$ - see front matter & 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2012.06.017
stigma and self-reported social functioning, while Cavelti et al. (in press) found support for an indirect relationship between selfstigma and social functioning (measured using a rating scale) that was mediated by the relationship between self-stigma and demoralization. However, a limitation in these studies is that the direction of the relationship is unclear, as diminished social functioning may lead to greater self-stigma. In a prospective study, Yanos et al. (2010b) found that baseline internalized stigma significantly negatively predicted improvement in vocational functioning (as measured by a rating scale) at 5 months follow-up, while controlling for positive and negative symptoms. However, more prospective studies are needed to determine the nature of the relationship between selfstigma and social functioning. The present study examined the relationship between changes in internalized stigma and functioning across three time points. It was hypothesized that degree of change in internalized stigma would be associated with degree of change in functioning over time, while controlling for symptoms and demographic variables.
2. Method 2.1. Procedures 2.1.1. Study context Data were drawn from a randomized controlled trial examining the effectiveness of targeted psychosocial treatment for internalized stigma in severe mental illness. Findings from the parent study are reported elsewhere (Yanos et al., in press). Participants were recruited from two sites: three assertive community treatment teams in New York City and a partial hospital program affiliated with a
P.T. Yanos et al. / Psychiatry Research 200 (2012) 1032–1034 Veterans Affairs center in Indianapolis, Indiana. Institutional Review Board approval was received for the study and participants provided informed consent.
2.2. Participants Participants were considered eligible if they demonstrated evidence of elevated internalized stigma, defined as scoring higher than a mean of 1.5 on the Internalized Stigma of Mental Illness Scale (ISMI; Ritsher and Phelan, 2004; see below) on an initial screening, and met criteria for schizophrenia, schizoaffective disorder, bipolar disorder or major depressive disorder on the Structured Clinical Interview for DSM-IV (SCID; Spitzer et al., 1994). These diagnostic categories are consistent with ‘‘broad’’ definitions of severe mental illness that have been discussed in the literature (Ruggeri et al., 2000). 38.8% of the screened participants met criteria for elevated internalized stigma. The 39 participants completing baseline assessments were predominantly (71.8%) male, middle-aged (mean ¼47.56 [S.D. ¼7.3]), with typically less than high school educations (mean ¼11.53 [S.D. ¼2.85]), and mean ages of first hospitalization of 24.82 (S.D. ¼ 9.16). Most participants met criteria for schizophrenia (28.2%) or schizoaffective (48.7%) disorders, while a minority met criteria for mood disorders (bipolar I: 12.8%, bipolar II: 7.7%, major depression: 2.6%). Participants were predominantly (69.2%) African-American, with 20.5% European-American, and 10.3% Hispanic.
2.2.1. Assessment schedule Interviews were conducted at baseline, post-treatment (roughly 4 months after baseline), and 3-months later. Thus, the time frame covered by the study period was roughly 7 months. Participants were paid $35 for completing the baseline interview and $25 each for the other interviews.
2.2.2. Training and inter-rater reliability Training on the assessment battery was provided to clinical interviewers, who demonstrated acceptable levels of inter-rater reliability on rating scales using training videos. After training, inter-rater reliability checks were performed on 10% of the interviews, based on simultaneous rating of interviews (see below).
2.3. Measures The Mood and Psychosis modules of the SCID (Spitzer et al., 1994) were used to assess primary diagnosis at baseline. The ISMI (Ritsher and Phelan, 2004) is a 29-item self-report questionnaire that was used to assess self-stigma. Mean imputation procedures were used to account for missing data; less than 0.01% of all items across the waves of the study were replaced using this method. Previous research provides evidence of good construct validity and reliability, and internal consistency was good across all three time points (alphas ranged from 0.75 to 0.91) in the present study. The Quality of Life Scale (QLS; Heinrichs et al., 1984) is a 21-item rating scale; despite its name, the QLS is widely accepted as a measure of social functioning and has been used as a measure of functioning in a number of studies, including the NIMH CATIE study (Swartz et al., 2006). The QLS has 4 factors: ‘‘Interpersonal Relations’’ (which assesses frequency of social contacts), ‘‘Intrapsychic Foundations’’ (which measures the qualitative aspects of interpersonal relationships), ‘‘Instrumental Functioning’’ (which taps vocational functioning) and ‘‘Commonplace Objects and Activities’’ (which assesses engagement in routine activities). High to excellent inter-rater reliability was found; with intraclass correlations for blind raters observing the same interview, 0.96 in the Indiana site and 0.94 in the New York site. The Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987), is a 30-item rating scale of psychiatric symptoms with five factors analytically derived components: Positive Symptoms, Negative Symptoms, Cognitive Symptoms, Hostility, and Emotional Discomfort. Though originally developed for schizophrenia, the PANSS has been found to be a valid measure of mood and psychotic symptoms in mixed diagnostic groups (Eisenberg et al., 2009). High inter-rater reliability was found, with intraclass correlations for blind raters observing the same interview, 0.91 in the New York site and 0.88 in the Indiana site.
2.4. Analyses We first explored correlations between internalized stigma, social functioning, symptoms and demographic variables at baseline. Next, we used mixed effects regression analyses (SAS ver. 9) to investigate the relationship between selfstigma, negative symptoms and social functioning (as measured by the QLS) over the three waves of the study. Advantages of mixed effects regression include its ability to tolerate missing data (thus, all participants with at least two observations could be included) and to estimate both fixed and random effects. Random effects estimation allows within-subjects variables (which vary at each time point for each participant) to differ across participants, so the procedure generates parameter estimates for within-subject variables for each individual.
1033
3. Results An examination of correlations between demographic variables, the ISMI, QLS and PANSS subscale scores at baseline (n¼ 39) revealed that QLS total scores were significantly positively related to gender (r ¼0.37, p o0.05, with women showing higher scores), and significantly negatively correlated with PANSS negative symptoms (r ¼ 0.57, p o0.01), PANSS cognitive symptoms (r ¼ 0.62, p o01) and ISMI total scores (r ¼ 0.32, p o0.05), but were not significantly related to any of the other variables studied. There was no evidence of a relationship between PANSS emotional discomfort, which assesses symptoms such as depression and anxiety, and QLS. There was also evidence of site differences in QLS scores, with participants in the Indiana site having significantly higher functioning (r¼0.41, po0.01). This suggests that the Indiana participants, possibly as a result of their histories of military service, tended to have higher functioning than the New York participants who tended to have histories of homelessness. Most participants (35 out of 39) completed at least one of the later interviews (either post-assessment or follow-up) and could be included in the mixed effects analyses (29 participants had data from all three study waves). T-tests were conducted to evaluate whether or not there were any significant differences in baseline scores between participants who did and did not drop out of assessments; the only difference was that drop-outs had lower mean QLS scores (t ¼2.00, p ¼0.05). This suggests that findings might be biased toward participants with better social functioning. We decided to include variables that were significantly associated with QLS score at baseline in the model; however we excluded PANSS cognitive symptoms as they were highly correlated with negative symptoms (r ¼0.67), leading to collinearity. Alternate models including cognitive symptoms in place of negative symptoms did not produce different results. In addition, gender, which was significantly associated with QLS at baseline, was excluded as it was found not to be significantly associated with QLS in the multivariate model and did not alter other findings. Table 1 presents findings from the mixed effects analysis of the relationship between ISMI total scores, PANSS negative symptoms, and QLS total scores over the three waves of the study. Analyses include data from 99 total observations with the 35 participants who had at least two observations. ISMI scores were allowed to vary randomly across participants. As can be seen in Table 1, results indicated that change in ISMI mean scores significantly negatively predicted QLS score over time, even when controlling for negative symptoms. Changes in negative symptoms, intercept (baseline ISMI scores), and interview wave were also significantly associated with change in QLS. These results indicate that increased self-stigma predicted lower quality of life over time controlling for the other variables that are included in the model.
4. Discussion Findings supported the hypothesis that change in internalized stigma is inversely associated with change in functioning over Table 1 Mixed regression predicting QLS total score across the three study waves. Outcome variable
Estimate
Stand. error
DF
T-value
P-value
Intercept Baseline Post-treatment Follow-up ISMI PANSS-negative
4.5969 0.2111 0.00833 0 0.3623 0.08827
0.2949 0.1012 0.09416
60 60 60
15.59 2.09 0.09
o 0.0001 0.0412 0.9298
0.1601 0.01122
38 60
2.26 7.87
0.0294 o 0.0001
1034
P.T. Yanos et al. / Psychiatry Research 200 (2012) 1032–1034
time, while controlling for symptoms and demographic factors. The finding in the present study is especially compelling because social functioning was measured with a rating scale, whereas internalized stigma was measured by a self-report, indicating that the relationship between these two variables is not attributable to ‘‘method variance.’’ Although the findings neither conclusively indicate that there is a causal relationship between internalized stigma and functioning, nor clarify the direction of the relationship between the two variables, they provide further support to the view that selfstigma and functioning are related and covary over time. Thus, findings support the view of Yanos et al. (2010a) that internalized stigma impacts social functioning, suggesting that interventions targeting internalized stigma might impact functioning. Some important limitations of the present study should be emphasized. First, the data were obtained from a predominantly male group of participants who initially met criteria for elevated internalized stigma. Thus, findings may not generalize to the broader group of individuals with severe mental illness who are not male and do not exhibit elevated internalized stigma. Second, despite its inclusion of multiple time points, the sample size was quite small, which further limits generalizability and statistical power. Future research should continue to explore the relationship between internalized stigma and social functioning with larger samples, with particular emphasis on how clinical interventions may impact these variables.
Acknowledgement The authors thank Mike Tamburino, Nicole Beattie, Amy Strasburger, Megan Grant, Lionel Wininger, and Andrea Rodrigues for their invaluable assistance in carrying out the study. This work was supported by National Institute of Mental Health grant R34MH082161 to the authors.
References ¨ Cavelti, M., Kvrgic, S., Beck, E.-M., Rusch, N., Vauth, R., 2012. Self-stigma and its relationship with insight, demoralization, and clinical outcome among people with schizophrenia spectrum disorders. Comprehensive Psychiatry 53, 468–479. Corrigan, P.W., Larson, J.E., Rusch, N., 2009. Self-stigma and the ‘‘why try’’ effect: impact on life goals and evidence-based practices. World Psychiatry 8, 75–81. Eisenberg, D.P., Aniskin, D.B., White, L., Stein, J.A., Harvey, P.D., Galynker, I.I., 2009. Structural differences within negative and depressive syndrome dimensions in schizophrenia, organic brain disease, and major depression: a confirmatory factor analysis of the Positive and Negative Syndrome Scale. Psychopathology 42, 242–248. Heinrichs, D.W., Hanlon, T.E., Carpenter, W.T., 1984. The quality of life scale: an instrument for assessing the schizophrenic deficit syndrome. Schizophrenia Bulletin 10, 388–396. Kay, S., Fiszbein, A., Opler, L., 1987. The Positive and Negative Syndrome Scale for schizophrenia. Schizophrenia Bulletin 13, 261–276. Livingston, J.D., Boyd, J.E., 2010. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and metaanalysis. Social Science and Medicine 71, 2150–2161. ˜ oz, M., Sanz, M., Pe´rez-Santos, E., de los A´ngeles Quiroga, M., 2011. Proposal of Mun a socio-cognitive-behavioral structural equation model of internalized stigma in people with severe and persistent mental illness. Psychiatry Research 30, 402–408. Ritsher, J.B., Phelan, J.C., 2004. Internalized stigma predicts erosion of morale among psychiatric outpatients. Psychiatry Research 129, 257–265. Ruggeri, M., Leese, M., Thornicroft, G., Bisoffi, G., Tansella, M., 2000. Definition and prevalence of severe and persistent mental illness. British Journal of Psychiatry 177, 149–155. Spitzer, R.L., Williams J.B., Gibbon M., First M., 1994. Structured Clinical Interview for DSM-IV. Swartz, M.S., Wagner, H.R., Swanson, J.W., Stroup, T.S., McEvoy, J.P., McGee, M., ˜ ive, J.M., Lieberman, J.A., 2006. Miller, D.D., Reimherr, F., Khan, A., Can Substance use and psychosocial functioning in schizophrenia among new enrollees in the NIMH CATIE study. Psychiatric Services 57, 1110–1116. Yanos, P.T., Roe, D., Lysaker, P.H., 2010a. The impact of illness identity on recovery from severe mental illness. American Journal of Psychiatric Rehabilitation 13, 73–93. Yanos, P.T., Lysaker, P.H., Roe, D., 2010b. Internalized stigma as a barrier to improvement in vocational functioning among people with schizophreniaspectrum disorders. Psychiatry Research 178, 211–213. Yanos P.T., Roe D., West M.L., Smith S.M., Lysaker P.H. Group-based treatment for internalized stigma among persons with severe mental illness: findings from a randomized controlled trial. Psychological Services, in press. doi is: http://dx. doi.org/10.1037/a0028048.
Contents lists available at SciVerse ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
Brief report
Change in internalized stigma and social functioning among persons diagnosed with severe mental illness Philip Theodore Yanos a,n, Michelle Leigh West a, Lauren Gonzales a, Stephen Mark Smith a, David Roe b, Paul Henry Lysaker c a
John Jay College of Criminal Justice, City University of New York, NY, USA Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel c Indiana University School of Medicine, Department of Psychiatry, Indianapolis, IN, USA b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 23 November 2011 Received in revised form 18 April 2012 Accepted 13 June 2012
This study examined the relationship between change in internalized stigma and social functioning over time. Thirty-five individuals with severe mental illness completed measures of self-stigma, social functioning and symptoms at baseline, 4 months, and 7 months. Change in self-stigma was significantly negatively related to change in social functioning, controlling for negative symptoms. & 2012 Elsevier Ireland Ltd. All rights reserved.
Keywords: Self-stigma Social functioning Negative symptoms
1. Introduction An accumulating body of evidence supports that internalized stigma, or self-stigma, is associated with compromised outcomes related to recovery from severe mental illness (Yanos et al., 2010a). In a meta-analysis of 45 studies, Livingston and Boyd (2010) found moderate to strong inverse relationships between self-stigma and self-esteem, hope, self-efficacy, social support, and subjective quality of life. A noted limitation of many of the reviewed studies, however, was that they almost exclusively employed cross-sectional designs. In addition, despite its central role in most definitions of recovery, social functioning (which includes vocational functioning and frequency of social contacts) has been rarely examined in relation to self-stigma (and thus was not included in Livingston and Boyd’s review). In their conceptual model of how self-stigma affects recovery, Yanos et al. (2010a) hypothesized that internalized stigma would compromise social functioning by leading to poorer vocational outcomes and increased social isolation. Similarly, Corrigan et al. (2009) hypothesized that self-stigma results in a ‘‘why try’’ effect which negatively impacts the pursuit of life goals. To date, three studies support that self-stigma is negatively ˜oz related to social functioning. In two cross-sectional studies, Mun et al. (2011) found a moderate relationship between internalized
n
Correspondance to: John Jay College of Criminal Justice, City University of New York, Psychology Department, 524 West 59th Street, NY 10019, USA. Tel.: þ 212 237 8773; fax: þ 212 237 8930. E-mail address: [email protected] (P.T. Yanos). 0165-1781/$ - see front matter & 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.psychres.2012.06.017
stigma and self-reported social functioning, while Cavelti et al. (in press) found support for an indirect relationship between selfstigma and social functioning (measured using a rating scale) that was mediated by the relationship between self-stigma and demoralization. However, a limitation in these studies is that the direction of the relationship is unclear, as diminished social functioning may lead to greater self-stigma. In a prospective study, Yanos et al. (2010b) found that baseline internalized stigma significantly negatively predicted improvement in vocational functioning (as measured by a rating scale) at 5 months follow-up, while controlling for positive and negative symptoms. However, more prospective studies are needed to determine the nature of the relationship between selfstigma and social functioning. The present study examined the relationship between changes in internalized stigma and functioning across three time points. It was hypothesized that degree of change in internalized stigma would be associated with degree of change in functioning over time, while controlling for symptoms and demographic variables.
2. Method 2.1. Procedures 2.1.1. Study context Data were drawn from a randomized controlled trial examining the effectiveness of targeted psychosocial treatment for internalized stigma in severe mental illness. Findings from the parent study are reported elsewhere (Yanos et al., in press). Participants were recruited from two sites: three assertive community treatment teams in New York City and a partial hospital program affiliated with a
P.T. Yanos et al. / Psychiatry Research 200 (2012) 1032–1034 Veterans Affairs center in Indianapolis, Indiana. Institutional Review Board approval was received for the study and participants provided informed consent.
2.2. Participants Participants were considered eligible if they demonstrated evidence of elevated internalized stigma, defined as scoring higher than a mean of 1.5 on the Internalized Stigma of Mental Illness Scale (ISMI; Ritsher and Phelan, 2004; see below) on an initial screening, and met criteria for schizophrenia, schizoaffective disorder, bipolar disorder or major depressive disorder on the Structured Clinical Interview for DSM-IV (SCID; Spitzer et al., 1994). These diagnostic categories are consistent with ‘‘broad’’ definitions of severe mental illness that have been discussed in the literature (Ruggeri et al., 2000). 38.8% of the screened participants met criteria for elevated internalized stigma. The 39 participants completing baseline assessments were predominantly (71.8%) male, middle-aged (mean ¼47.56 [S.D. ¼7.3]), with typically less than high school educations (mean ¼11.53 [S.D. ¼2.85]), and mean ages of first hospitalization of 24.82 (S.D. ¼ 9.16). Most participants met criteria for schizophrenia (28.2%) or schizoaffective (48.7%) disorders, while a minority met criteria for mood disorders (bipolar I: 12.8%, bipolar II: 7.7%, major depression: 2.6%). Participants were predominantly (69.2%) African-American, with 20.5% European-American, and 10.3% Hispanic.
2.2.1. Assessment schedule Interviews were conducted at baseline, post-treatment (roughly 4 months after baseline), and 3-months later. Thus, the time frame covered by the study period was roughly 7 months. Participants were paid $35 for completing the baseline interview and $25 each for the other interviews.
2.2.2. Training and inter-rater reliability Training on the assessment battery was provided to clinical interviewers, who demonstrated acceptable levels of inter-rater reliability on rating scales using training videos. After training, inter-rater reliability checks were performed on 10% of the interviews, based on simultaneous rating of interviews (see below).
2.3. Measures The Mood and Psychosis modules of the SCID (Spitzer et al., 1994) were used to assess primary diagnosis at baseline. The ISMI (Ritsher and Phelan, 2004) is a 29-item self-report questionnaire that was used to assess self-stigma. Mean imputation procedures were used to account for missing data; less than 0.01% of all items across the waves of the study were replaced using this method. Previous research provides evidence of good construct validity and reliability, and internal consistency was good across all three time points (alphas ranged from 0.75 to 0.91) in the present study. The Quality of Life Scale (QLS; Heinrichs et al., 1984) is a 21-item rating scale; despite its name, the QLS is widely accepted as a measure of social functioning and has been used as a measure of functioning in a number of studies, including the NIMH CATIE study (Swartz et al., 2006). The QLS has 4 factors: ‘‘Interpersonal Relations’’ (which assesses frequency of social contacts), ‘‘Intrapsychic Foundations’’ (which measures the qualitative aspects of interpersonal relationships), ‘‘Instrumental Functioning’’ (which taps vocational functioning) and ‘‘Commonplace Objects and Activities’’ (which assesses engagement in routine activities). High to excellent inter-rater reliability was found; with intraclass correlations for blind raters observing the same interview, 0.96 in the Indiana site and 0.94 in the New York site. The Positive and Negative Syndrome Scale (PANSS; Kay et al., 1987), is a 30-item rating scale of psychiatric symptoms with five factors analytically derived components: Positive Symptoms, Negative Symptoms, Cognitive Symptoms, Hostility, and Emotional Discomfort. Though originally developed for schizophrenia, the PANSS has been found to be a valid measure of mood and psychotic symptoms in mixed diagnostic groups (Eisenberg et al., 2009). High inter-rater reliability was found, with intraclass correlations for blind raters observing the same interview, 0.91 in the New York site and 0.88 in the Indiana site.
2.4. Analyses We first explored correlations between internalized stigma, social functioning, symptoms and demographic variables at baseline. Next, we used mixed effects regression analyses (SAS ver. 9) to investigate the relationship between selfstigma, negative symptoms and social functioning (as measured by the QLS) over the three waves of the study. Advantages of mixed effects regression include its ability to tolerate missing data (thus, all participants with at least two observations could be included) and to estimate both fixed and random effects. Random effects estimation allows within-subjects variables (which vary at each time point for each participant) to differ across participants, so the procedure generates parameter estimates for within-subject variables for each individual.
1033
3. Results An examination of correlations between demographic variables, the ISMI, QLS and PANSS subscale scores at baseline (n¼ 39) revealed that QLS total scores were significantly positively related to gender (r ¼0.37, p o0.05, with women showing higher scores), and significantly negatively correlated with PANSS negative symptoms (r ¼ 0.57, p o0.01), PANSS cognitive symptoms (r ¼ 0.62, p o01) and ISMI total scores (r ¼ 0.32, p o0.05), but were not significantly related to any of the other variables studied. There was no evidence of a relationship between PANSS emotional discomfort, which assesses symptoms such as depression and anxiety, and QLS. There was also evidence of site differences in QLS scores, with participants in the Indiana site having significantly higher functioning (r¼0.41, po0.01). This suggests that the Indiana participants, possibly as a result of their histories of military service, tended to have higher functioning than the New York participants who tended to have histories of homelessness. Most participants (35 out of 39) completed at least one of the later interviews (either post-assessment or follow-up) and could be included in the mixed effects analyses (29 participants had data from all three study waves). T-tests were conducted to evaluate whether or not there were any significant differences in baseline scores between participants who did and did not drop out of assessments; the only difference was that drop-outs had lower mean QLS scores (t ¼2.00, p ¼0.05). This suggests that findings might be biased toward participants with better social functioning. We decided to include variables that were significantly associated with QLS score at baseline in the model; however we excluded PANSS cognitive symptoms as they were highly correlated with negative symptoms (r ¼0.67), leading to collinearity. Alternate models including cognitive symptoms in place of negative symptoms did not produce different results. In addition, gender, which was significantly associated with QLS at baseline, was excluded as it was found not to be significantly associated with QLS in the multivariate model and did not alter other findings. Table 1 presents findings from the mixed effects analysis of the relationship between ISMI total scores, PANSS negative symptoms, and QLS total scores over the three waves of the study. Analyses include data from 99 total observations with the 35 participants who had at least two observations. ISMI scores were allowed to vary randomly across participants. As can be seen in Table 1, results indicated that change in ISMI mean scores significantly negatively predicted QLS score over time, even when controlling for negative symptoms. Changes in negative symptoms, intercept (baseline ISMI scores), and interview wave were also significantly associated with change in QLS. These results indicate that increased self-stigma predicted lower quality of life over time controlling for the other variables that are included in the model.
4. Discussion Findings supported the hypothesis that change in internalized stigma is inversely associated with change in functioning over Table 1 Mixed regression predicting QLS total score across the three study waves. Outcome variable
Estimate
Stand. error
DF
T-value
P-value
Intercept Baseline Post-treatment Follow-up ISMI PANSS-negative
4.5969 0.2111 0.00833 0 0.3623 0.08827
0.2949 0.1012 0.09416
60 60 60
15.59 2.09 0.09
o 0.0001 0.0412 0.9298
0.1601 0.01122
38 60
2.26 7.87
0.0294 o 0.0001
1034
P.T. Yanos et al. / Psychiatry Research 200 (2012) 1032–1034
time, while controlling for symptoms and demographic factors. The finding in the present study is especially compelling because social functioning was measured with a rating scale, whereas internalized stigma was measured by a self-report, indicating that the relationship between these two variables is not attributable to ‘‘method variance.’’ Although the findings neither conclusively indicate that there is a causal relationship between internalized stigma and functioning, nor clarify the direction of the relationship between the two variables, they provide further support to the view that selfstigma and functioning are related and covary over time. Thus, findings support the view of Yanos et al. (2010a) that internalized stigma impacts social functioning, suggesting that interventions targeting internalized stigma might impact functioning. Some important limitations of the present study should be emphasized. First, the data were obtained from a predominantly male group of participants who initially met criteria for elevated internalized stigma. Thus, findings may not generalize to the broader group of individuals with severe mental illness who are not male and do not exhibit elevated internalized stigma. Second, despite its inclusion of multiple time points, the sample size was quite small, which further limits generalizability and statistical power. Future research should continue to explore the relationship between internalized stigma and social functioning with larger samples, with particular emphasis on how clinical interventions may impact these variables.
Acknowledgement The authors thank Mike Tamburino, Nicole Beattie, Amy Strasburger, Megan Grant, Lionel Wininger, and Andrea Rodrigues for their invaluable assistance in carrying out the study. This work was supported by National Institute of Mental Health grant R34MH082161 to the authors.
References ¨ Cavelti, M., Kvrgic, S., Beck, E.-M., Rusch, N., Vauth, R., 2012. Self-stigma and its relationship with insight, demoralization, and clinical outcome among people with schizophrenia spectrum disorders. Comprehensive Psychiatry 53, 468–479. Corrigan, P.W., Larson, J.E., Rusch, N., 2009. Self-stigma and the ‘‘why try’’ effect: impact on life goals and evidence-based practices. World Psychiatry 8, 75–81. Eisenberg, D.P., Aniskin, D.B., White, L., Stein, J.A., Harvey, P.D., Galynker, I.I., 2009. Structural differences within negative and depressive syndrome dimensions in schizophrenia, organic brain disease, and major depression: a confirmatory factor analysis of the Positive and Negative Syndrome Scale. Psychopathology 42, 242–248. Heinrichs, D.W., Hanlon, T.E., Carpenter, W.T., 1984. The quality of life scale: an instrument for assessing the schizophrenic deficit syndrome. Schizophrenia Bulletin 10, 388–396. Kay, S., Fiszbein, A., Opler, L., 1987. The Positive and Negative Syndrome Scale for schizophrenia. Schizophrenia Bulletin 13, 261–276. Livingston, J.D., Boyd, J.E., 2010. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and metaanalysis. Social Science and Medicine 71, 2150–2161. ˜ oz, M., Sanz, M., Pe´rez-Santos, E., de los A´ngeles Quiroga, M., 2011. Proposal of Mun a socio-cognitive-behavioral structural equation model of internalized stigma in people with severe and persistent mental illness. Psychiatry Research 30, 402–408. Ritsher, J.B., Phelan, J.C., 2004. Internalized stigma predicts erosion of morale among psychiatric outpatients. Psychiatry Research 129, 257–265. Ruggeri, M., Leese, M., Thornicroft, G., Bisoffi, G., Tansella, M., 2000. Definition and prevalence of severe and persistent mental illness. British Journal of Psychiatry 177, 149–155. Spitzer, R.L., Williams J.B., Gibbon M., First M., 1994. Structured Clinical Interview for DSM-IV. Swartz, M.S., Wagner, H.R., Swanson, J.W., Stroup, T.S., McEvoy, J.P., McGee, M., ˜ ive, J.M., Lieberman, J.A., 2006. Miller, D.D., Reimherr, F., Khan, A., Can Substance use and psychosocial functioning in schizophrenia among new enrollees in the NIMH CATIE study. Psychiatric Services 57, 1110–1116. Yanos, P.T., Roe, D., Lysaker, P.H., 2010a. The impact of illness identity on recovery from severe mental illness. American Journal of Psychiatric Rehabilitation 13, 73–93. Yanos, P.T., Lysaker, P.H., Roe, D., 2010b. Internalized stigma as a barrier to improvement in vocational functioning among people with schizophreniaspectrum disorders. Psychiatry Research 178, 211–213. Yanos P.T., Roe D., West M.L., Smith S.M., Lysaker P.H. Group-based treatment for internalized stigma among persons with severe mental illness: findings from a randomized controlled trial. Psychological Services, in press. doi is: http://dx. doi.org/10.1037/a0028048.