TYPE Original Research

PUBLISHED 05 June 2024

DOI 10.3389/fpsyt.2024.1366030

The relationship between self-

OPEN ACCESS stigma and quality of life in long-
EDITED BY
Massimo Tusconi,
University of Cagliari, Italy
term hospitalized patients with
REVIEWED BY
Clara Isabel Morgades-Bamba,
schizophrenia: a cross-
Universidad Nacional de Educación a
Distancia, Spain
Gabriele Nibbio,
sectional study
University of Brescia, Italy
Serdar M. Dursun, Fuquan Liu 1, Hu Deng 1, Na Hu 1, Wenqian Huang 1, Hong Wang 1,
University of Alberta, Canada
Lin Liu 1*, Jiabao Chai 1* and Ying Li 2
*CORRESPONDENCE
Jiabao Chai Beijing Huilongguan Hospital, Peking University Huilongguan Clinical Medical School, Beijing, China,
1

[email protected] 2
Department of Psychosomatic Medicine, Beijing Children’s Hospital, Capital Medical University,
Lin Liu National Center for Children Healthy, Beijing, China
[email protected]

RECEIVED 19 January 2024

ACCEPTED 01 May 2024 Objective: To investigate self-stigma’s influence on schizophrenia patients’
PUBLISHED 05 June 2024
quality of life and its mediated impact by various factors.
CITATION
Liu F, Deng H, Hu N, Huang W, Wang H, Liu L,
Methods: This study adopted a cross-sectional design and randomly selected
Chai J and Li Y (2024) The relationship
between self-stigma and quality of life in 170 hospitalized patients with schizophrenia for evaluation. The assessment tools
long-term hospitalized patients with included the Positive and Negative Syndrome Scale (PANSS), Internalized Stigma
schizophrenia: a cross-sectional study.
Front. Psychiatry 15:1366030.
of Mental Illness Scale (ISMI), Schizophrenia Quality of Life Scale (SQLS), and
doi: 10.3389/fpsyt.2024.1366030 Coping Questionnaire for Schizophrenia Patients (CQSP), among others.
COPYRIGHT Correlation analysis, regression analysis, and mediation analysis were used to
© 2024 Liu, Deng, Hu, Huang, Wang, Liu, Chai test the correlation and mediation effects.
and Li. This is an open-access article
distributed under the terms of the Creative
Commons Attribution License (CC BY). The Results: Self-stigma had a significant impact on quality of life (T = 8.13, p = 0.00).
use, distribution or reproduction in other When self-stigma is used as a mediator, the problem-solving factor in coping
forums is permitted, provided the original
author(s) and the copyright owner(s) are
strategies has an indirect effect on quality of life, which is significant (AB = -0.16, P
credited and that the original publication in = 0.02), while the avoidance factor in coping strategies has a direct effect on
this journal is cited, in accordance with quality of life, which is significant (C’ = 0.54, p < 0.001), and an indirect effect,
accepted academic practice. No use,
distribution or reproduction is permitted which is also significant (AB = 0.25, p < 0.001).
which does not comply with these terms.
Conclusion: The study highlights the significant impact of self-stigma on the
quality of life of schizophrenia patients, emphasizing the crucial roles of self-
esteem and coping strategies. These findings suggest clinical interventions to
improve quality of life should focus on reducing self-stigma, especially
enhancing self-esteem and promoting adaptive coping strategies. By
addressing these factors, we can better support the mental health and well-
being of those with schizophrenia, offering an effective approach
to rehabilitation.

KEYWORDS

schizophrenia, self-stigma, quality of life, self-esteem, coping strategies

Frontiers in Psychiatry 01 frontiersin.org

Liu et al. 10.3389/fpsyt.2024.1366030

1 Background further investigation. In China, long-term hospitalized patients with

schizophrenia account for the largest proportion of inpatient cases
Mental illness stigma (1) refers to the stigmatization of people (22, 23), and their quality of life has attracted the attention and
with mental illness, which can be divided into self-stigma (2) and research of many scholars (24–26), but further investigation is
public stigma (3). The former refers to the stigmatizing attitude of needed to explore the relationship between self-stigma and
patients toward themselves, while the latter refers to the personal quality of life.
experiences of discrimination and unfair treatment that patients Therefore, the aims of this study are 1) to investigate the
face from society and the public (4). In addition to the fear and relationship between self-stigma and quality of life in patients with
avoidance of social and public discrimination, including chronic schizophrenia, particularly which factors of self-stigma have a
stereotypes, prejudices, and discrimination, self-stigma also greater impact on quality of life, and 2) to explore the influencing
involves a sense of shame that hinders people from talking about factors of self-stigma and whether these factors affect quality of life via
their experiences and seeking help (5). Schizophrenia is defined as a self-stigma. We hypothesize that all factors of self-stigma are related
severe mental illness that generally requires long-term social and to quality of life and that the factors influencing self-stigma indirectly
functional rehabilitation (6, 7). Nevertheless, the internalization of or directly affect quality of life via self-stigma. We plan to use multiple
stigma related to schizophrenia is linked to a poorer prognosis and linear regression to investigate the influencing factors of self-stigma,
heightened suicidal tendencies (8). Self-stigma is an important and a mediation model will also be used to explore the mediating
obstacle to the social and functional rehabilitation of patients effect of self-stigma on quality of life.
with schizophrenia (9). Stigma experienced by individuals with
schizophrenia leads to a lack of self-esteem (10) and continuous
self-deprecation and limits normal life and social interactions, 2 Methods
ultimately resulting in adverse consequences such as avoidance of
social situations, depression, suicide, and a decreased quality of life 2.1 Participants
(11, 12). Therefore, it is important to focus on exploring self-stigma
in schizophrenia and its impact on the quality of life of This is a cross-sectional study based on hospitalized patients
those affected. with schizophrenia. 170 inpatients with schizophrenia from
Studies on self-stigma in the context of schizophrenia have Huilongguan Hospital in Beijing were selected as the subjects of
revealed a direct correlation: as the severity of the mental illness the study using the random number table method. We conducted a
increases and the number of hospitalizations rises, the intensity of study over a five-month period from June 2023 to October 2023,
self-stigma also escalates (13). Self-stigma leads to decreased self- collecting data from patients at Beijing Huilonguan Hospital. All
esteem, reduced hope, restricted social interaction, and decreased participants in the study were aged between 18 and 55 years.
compliance (14). It increases self-isolation and reluctance to accept Additionally, every patient was capable of independently
treatment and other support, exacerbating the recurrence of mental completing the questionnaire assessments without the need for
illness and seriously affecting the recovery process (15). These assistance from medical staff. According to the WHO ICD-10 (27)
proximal effects can also have potential distal consequences, such criteria for the diagnosis of schizophrenia, all patients had been
as hindering the pursuit of life goals, reducing community diagnosed with schizophrenia by at least two experienced
engagement, impeding social relationships and social support, psychiatrists. Eligible subjects were included in the study and
and ultimately affecting quality of life (16). A meta-analysis of 54 written informed consent and demographic and clinical
studies conducted by Gerlinger et al. showed that perceived or information were obtained from the patients. This study was
experienced shame is associated with more severe depressive approved by the Ethics Committee of Beijing Huilongguan
symptoms, greater social anxiety and avoidance behaviors, low Hospital. approved with grant number: 202324 section.
self-esteem, poorer social functioning, and overall lower quality of
life (17). The self-stigma of patients with schizophrenia is closely
related to their quality of life (18), but there is still insufficient 2.2 Inclusion and exclusion criteria
research on long-term hospitalized patients. The harm of self-
stigma manifests itself in various ways, as it weakens self-esteem The inclusion criteria were as follows: (1) patients diagnosed
and self-worth and undermines the hope and optimism of achieving with schizophrenia according to ICD-10; (2) stable medication use
goals (19, 20). for at least 2 months; (3) aged between 18 and 55 years; (4)
At the same time, self-stigma is influenced by various factors. education level of junior high school or above; and (5) illness
Ritsher et al. developed a five-factor scale for self-stigma, including duration of ≥ 5 years. The exclusion criteria were as follows: (1)
self-esteem, psychological resilience, coping strategies, social patients with major physical illnesses; (2) patients with organic
support, etc. (21). These factors have different degrees of brain disorders or a history of head trauma, significant intellectual
influence on self-stigma, but a systematic exploration of the disability, or other severe, uncontrollable physical illnesses; and (3)
factors affecting self-stigma is lacking. Moreover, whether these patients with psychiatric disorders caused by substance abuse such
influencing factors affect quality of life via self-stigma also needs as alcoholism or drug addiction.

Frontiers in Psychiatry 02 frontiersin.org

Liu et al. 10.3389/fpsyt.2024.1366030

2.3 Psychopathological assessment the item scores of each subscale is the total score of the subscale, and
the higher the score.
All participants were assessed using questionnaires, which were A high score indicates that the coping style is more used to it.
administered by two experienced psychiatrists. The intraclass The questionnaire uses a 5-point Likert scale. The subjects had to
correlation coefficient (ICC) indicated good consistency between choose each coping method (item) according to their own situation
raters (ICC = 0.80) in terms of rating scales. (1: I never use it, 2: I use it occasionally, 3: I use it more often, 4: I
use it often, 5: I always use it). Cronbach’s a coefficient is 0.68
2.3.1 Positive and negative syndrome scale -0.95 (39).
The PANSS (28) scale is widely used to assess three main
dimensions: positive syndrome (PANSS-P), negative syndrome 2.3.7 Social support rating scale
(PANSS-N), and general psychopathology (GP). The values range The SSRS (40) scale was used to measure the social support level
from 1 (“absent”) to 7 (“extreme”). The scale’s total score ranges of the participants (Cronbach a coefficient 0.80, P<0.001). The SSRS
between 30 and 210 points, with higher scores indicating more has 10 items in total, which are divided into three dimensions:
severe symptoms. It serves as a tool for gauging the severity of “objective support”, “subjective support”, and “support utilization”.
symptoms in study participants. The internal consistency was good The total score is the sum of the scores of all ten items. The higher
(Cronbach’s a>0.70) (29). the score, the higher the social support level. A total score that is at
most 22 is classified as a low level of social support, a score between
2.3.2 Self-esteem inventory 23 and 44 is classified as a medium level, and a score between 45 and
The SEI (30) scale has a total of 58 questions, using a two-point 66 is classified as a high level. Cronbach’s a coefficient is 0.63 (41).
scoring method: 1 point for being like me and 0 for not being like
me. There are 30 questions in reverse scoring, The total score ranges
from 0 to 50, and the higher the total score is, the higher the self- 2.4 Statistical analysis
esteem level. The internal consistency coefficient of Cronbach
Alpha of SEI was 0.86 (31). Statistical analyses were conducted following CONSORT
guidelines and were performed using SPSS 22.0 software (SPSS,
Chicago, IL, USA). The applied statistical methods were descriptive
2.3.3 Connor-Davidson resilience scale
statistics for the demographic data, mean scores, and normality
The CD-RISC (32) consists of 25 items rated on a 5-point
tests. First, we analyzed the basic information using descriptive
similar scale, ranging from 0 (“not true at all”) to 4 (“true almost all
statistics, which included percentages, mean values, and standard
of the time”). The total score ranges from 0 to 100, with higher
deviations. It is particularly important to emphasize that, to ensure
scores indicating greater resilience. Cronbach’s alpha was 0.92 (33).
consistency in dosage calculations, all medications taken by patients
for the treatment of schizophrenia were converted into equivalent
2.3.4 Internalized stigma of mental illness doses of olanzapine (42). Next, differences between scores were
The ISMI (34) Scale, which contains 29 items distributed among calculated by parametric or nonparametric paired or unpaired t
five subscales that capture various aspects of the subjective tests or Kruskal–Wallis tests. We utilized regression analysis to
experience of stigma: alienation, stereotype endorsement, predict the impact of the total self-stigma score and its respective
perceived discrimination, social withdrawal and stigma resistance. factors on quality of life while also conducting correlation analysis
These items are assessed on a 4-point scale, from 1 to 4, yielding a to assess their associations with the total score and factors of quality
total possible score range of 29 to 116. The higher the score is, the of life. Finally, effect sizes were interpreted by Cohen. Citation51 A
greater the internalized stigma. Cronbach’s a coefficient is 0.94 (35). mediation analysis was performed by using the maximum
likelihood method with standardized estimates. We performed
mediation analysis to analyze the effects of self-esteem, coping
2.3.5 Schizophrenia quality of life scale
strategies (1, 2), self-stigma, and quality of life. Direct and
The SQLS (36) has a total of 30 items, which are divided into
indirect effects were utilized to elucidate the relationship among
three subscales to evaluate psychosocial factors, motivation and
these variables. Differences were significant when P values were less
energy, symptoms and side effects, respectively, using a 5-point
than 0.05.
scale (0-4). Each scale is scored from 0-100, and the higher the
score, the worse the quality of life. Cronbach’s a coefficient is 0.83
-0.72 (37).
3 Results
2.3.6 Coping questionnaire for 3.1 Demographic data
schizophrenic patients
The CQSP (38) scale has 54 items, and the questionnaire Out of 182 reviewed inpatients with schizophrenia, 170 were
includes four subscales: “Problem Solving”, “Avoidance”, included in the study. The mean age of the study population was
“Cognitive Adjustment” and “Emotion Regulation”. The sum of 51.46 years. Among the study population, 67.7% (115) were male

Frontiers in Psychiatry 03 frontiersin.org

Liu et al. 10.3389/fpsyt.2024.1366030

and 33.3% (55) were female, with a mean age of 51.46 ± 12.52. indirect effect of self-esteem on quality of life via self-stigma was not
Other demographic data, such as length of hospitalization and significant (AB = -0.15, p = 0.08). Further details can be found
educational level, as well as clinical symptom-related assessments in Figure 1.
(including PANSS, SEI, CD-RISC, ISMI, SQLS, CQSP, SSRS), are On the other hand, the analysis showed a significant indirect
shown in Table 1. effect of problem-solving coping style on quality of life via self-
stigma (AB = -0.16, p = 0.02). This suggests that the problem-

3.2 Prediction of total self-stigma score on

TABLE 1 Description of basic subject information.
overall quality of life (regression analysis)
Category Figures or mean values
The results showed a significant impact of the total self-stigma
Number of patients 170
score on quality of life (F = 12.56, P = 0.000b, Beat = 0.56, T = 8.13, p
= 0.00). Age 51.46 ± 12.52

Sex: men/women 115/55

Education Year 12.02 ± 2.91

3.3 Correlation analysis between total and
subscores of self-stigma and quality of life Course 22.00 ± 13.04

Onset 29.31 ± 10.32

The results showed that there were significant correlations
Drug dosage 10.80 ± 6.68
between the total and subscores of self-stigma and the total and
subscores of quality of life. See Table 2 for details. Additionally, we PANSS-P 19.15 ± 3.36
conducted a correlation analysis between self-stigma and PANSS-N 19.58 ± 4.50
sociodemographic characteristics; however, no significant results
PANSS-G 37.33 ± 9.32
were identified.
PANSS-Total score 76.06 ± 9.32

SSRS-O 4.84 ± 2.82

3.4 Regression analysis of self-stigma
SSRS-S 9.41 ± 2.53
factors on overall quality of life score
SSRS-U 6.96 ± 2.31
The results showed that perceived discrimination (T = 2.22, p = SSRS-Total score 21.21 ± 5.68
0.03) and stigma resistance (T = 2.65, p = 0.01) in the self-stigma
CD-RISC-F1 19.14 ± 6.17
factors had a significant impact on quality of life, while the other
self-stigma factors had no significant impact on the overall quality CD-RISC-F2 15.24 ± 4.56
of life score. See Table 3 for details (R2 = 0.37, Adjusted R2 = 0.35). CD-RISC-F3 12.46 ± 4.25

CD-RISC-F4 6.84 ± 2.94

3.5 Factors influencing self-stigma CD-RISC-F5 4.43 ± 1.65

CD-RISC-Total score 58.10 ± 16.27

The relationship between various factors in the PANSS, SEI,
ISMI-A 20.86 ± 5.66
CQSP, SSRS, and CD-RISC and self-stigma was explored. The
results showed that self-esteem (T = -2.11, p = 0.04), coping style ISMI-SE 16.25 ± 4.64
1 (problem-solving factor) (T = -2.58, p = 0.01), and coping style 2 ISMI-PD 11.40 ± 3.163
(avoidance factor) (T = 4.65, p = 0.00) had a greater impact on self-
ISMI-SW 6.95 ± 2.45
stigma. See Table 4 for details (R2 = 0.46, Adjusted R2 = 0.42).
ISMI-SR 11.12 ± 3.22

ISMI-Total score 66.58 ± 16.94

3.6 Exploring whether these three factors
SQLS-P 20.79 ± 11.49
(self-esteem, problem-solving coping style,
and avoidance coping style) affect quality SQLS-ME 11.05 ± 4.07
of life via self-stigma SQLS-SSE 9.42 ± 5.90

SQLS-Total score 41.26 ± 18.67

Mediation analysis was conducted to examine the relationships
between self-esteem, coping strategies (problem-solving and CQSP-PS 67.13 ± 17.84

avoidance), self-stigma, and quality of life. The results revealed CQSP-A 37.08 ± 10.27
that self-esteem had a significant effect on quality of life (C´ = -0.45,
(Continued)
p = 0.04), as did self-stigma (C = -0.60, p = 0.02). However, the

Frontiers in Psychiatry 04 frontiersin.org

Liu et al. 10.3389/fpsyt.2024.1366030

TABLE 1 Continued
4 Discussion
Category Figures or mean values
The main results of this study are as follows: First, self-stigma
CQSP-CA 31.24 ± 8.82
significantly impacts quality of life, with perceived discriminations
CQSP-ER 19.5 ± 5.03 and stigma resistance within the self-stigma factors significantly
CQSP-Total score 154.94 ± 35.04
affecting quality of life. Second, self-esteem, problem-solving coping
style, and avoidance coping style have a significant influence on self-
SEI-Total score 35.05 ± 7.68
stigma. Last, problem-solving coping style (Factor 1) exerts an effect
PANSS, Positive and Negative Syndrome Scale; PANSS-P, Positive and Negative Syndrome on quality of life via self-stigma, with a significant mediating effect.
Scale (Positive syndrome); PANSS-N, Positive and Negative Syndrome Scale (Negative
syndrome); PANSS-G, Positive and Negative Syndrome Scale (General psychopathology); Similarly, avoidance coping style (Factor 2) affects quality of life via
SSRS, Social Skills Rating Scale; SSRS-O, Social Skills Rating Scale (Objective support) ; SSRS- self-stigma, also showing a significant mediating effect.
S, Social Skills Rating Scale (Subjective support) ; SSRS-U, Social Skills Rating Scale
(Utilization of support);CD-RISC, Connor- Davidson resilience scale; CD-RISC-F1, This study found a significant impact of self-stigma on the
Connor-Davidson Resilience Scale (Adversity); CD-RISC-F2, Connor-Davidson Resilience quality of life of individuals with schizophrenia, with perceived
Scale (Persistence); CD-RISC-F3, Connor-Davidson Resilience Scale (Adaptability); CD-
RISC-F4, Connor-Davidson Resilience Scale (Positive Acceptance); CD-RISC-F5, Connor-
discriminations and stigma resistance being significant factors
Davidson Resilience Scale (Secure Relationships); SQLS, Schizophrenia Quality of Life Scale; within the self-stigma construct. In a study examining self-stigma,
SQLS-P, Schizophrenia Quality of Life Scale (Psychosocial); SQLS-ME, Schizophrenia Quality
of Life Scale (Motivation and energy); SQLS- (SSE), Schizophrenia Quality of Life Scale
sleep quality, and quality of life among individuals with mental
(Symptoms and side Effects); ISMI, Internalized Stigma of Mental Illness; ISMI-A, disorders, it was found that self-stigma influences quality of life by
Internalized Stigma of Mental Illness (Alienation); ISMI-SE, Internalized Stigma of Mental
Illness (Stereotype Endorsement); ISMI-PD, Internalized Stigma of Mental Illness (Perceived
affecting sleep quality (43). A multinational study conducted in the
Discrimination); ISMI-SW, Internalized Stigma of Mental Illness (Social Withdrawal); ISMI- Americas revealed a significant impact of self-stigma on quality of
SR, Internalized Stigma of Mental Illness (Stigma Resistance); CQSP, Coping Questionnaire
life (44). A cross-sectional survey involving 153 individuals with
for Schizophrenic Patients; CQSP-PS, Coping Questionnaire for Schizophrenic Patients
(Problem Solving); CQSP-A, Coping Questionnaire for Schizophrenic Patients (Avoidance); mental disorders showed that among the various psychological or
CQSP-CA, Coping Questionnaire for Schizophrenic Patients (Cognitive Adjustment); CQSP- social influences on quality of life, self-stigma emerged as the most
ER, Coping Questionnaire for Schizophrenic Patients (Emotion Regulation); SEI, Self-
esteem Inventory. significant factor (45). Another study that included a systematic
review of 63 articles (N = 8925, 22 countries) and a meta-analysis of
solving coping style influences quality of life by affecting self-stigma. 53 articles (N = 7756) revealed a strong negative correlation
Additionally, the results indicated that the avoidance coping style between self-stigma and quality of life (46). Many studies have
had both significant direct effects (C’ = 0.54, p < 0.001) and shown that a significant factor contributing to self-stigma is public
significant indirect effects (AB = 0.25, p < 0.001) on quality of life stigma (47–49), and stigma pressure from society leads to social
via self-stigma. This suggests a partial mediation effect, where lower withdrawal among individuals with mental illness (50, 51).
avoidance scores are associated with lower self-stigma and higher Which factors influence self-stigma? This study found that
quality of life. Further details can be found in Figure 2. among the various factors explored, self-esteem, problem-solving

TABLE 2 Correlation analysis between self-stigma score and its factors and quality of life score and factors.

ISMI-
SQLS- SQLS- SQLS- SQLS-
ISMI-A ISMI-SE ISMI-PD ISMI-SW ISMI-SR Total
P ME SSE Total score
score
SQLS-P 1

SQLS-ME 0.39** 1

SQLS-SSE 0.80** 0.41** 1

SQLS-
0.96** 0.60** 0.90** 1
Total score

ISMI-A 0.54** 0.28** 0.47** 0.54** 1

ISMI-SE 0.53** 0.29** 0.47** 0.54** 0.82** 1

ISMI-PD 0.51** 0.27** 0.50** 0.53** 0.71** 0.73** 1

ISMI-SW 0.44** 0.19* 0.35** 0.43** 0.70** 0.70** 0.62** 1

ISMI-SR 0.46** 0.21** 0.41** 0.46** 0.78** 0.79** 0.72** 0.69** 1

ISMI-
0.57** 0.29** 0.50** 0.57** 0.93** 0.93** 0.85** 0.81** 0.89** 1
Total score

Note: *P<0.05, **P<0.01. SQLS, Schizophrenia Quality of Life Scale; ISMI, Internalized Stigma of Mental Illness; SQLS-P, Schizophrenia Quality of Life Scale(Psychosocial); SQLS-ME,
Schizophrenia Quality of Life Scale(Motivation and energy); SQLS-(SSE), Schizophrenia Quality of Life Scale(Symptoms and side Effects); ISMI-A, Internalized Stigma of Mental Illness
(Alienation); ISMI-SE, Internalized Stigma of Mental Illness(Stereotype Endorsement); ISMI-PD, Internalized Stigma of Mental Illness (Perceived Discrimination); ISMI-SW, Internalized
Stigma of Mental Illness (Social Withdrawal); ISMI-SR, Internalized Stigma of Mental Illness (Stigma Resistance).

Frontiers in Psychiatry 05 frontiersin.org

Liu et al. 10.3389/fpsyt.2024.1366030

TABLE 3 The regression analysis of self-stigma factors for total quality of life scores.

Dependent Variable Predictors Beta T P

ISMI-A 0.17 1.39 0.17
SQLS
(F = 8.99) ISMI-SE 0.28 2.22 0.03*
(P = 0.000b)
ISMI-PD 0.27 2.65 0.01*

ISMI-SW -0.02 -0.17 0.87

ISMI-SR -0.08 -0.65 0.51

SQLS, Schizophrenia Quality of Life Scale; ISMI, Internalized Stigma of Mental Illness; ISMI-A, Internalized Stigma of Mental Illness (Alienation); ISMI-SE, Internalized Stigma of Mental Illness
(Stereotype Endorsement); ISMI-PD, Internalized Stigma of Mental Illness (Perceived Discrimination); ISMI-SW, Internalized Stigma of Mental Illness (Social Withdrawal); ISMI-SR,
Internalized Stigma of Mental Illness (Stigma Resistance). * p < 0.05.

coping style, and avoidance coping style have significant effects on 54). Our study’s findings align with the aforementioned research
self-stigma. Sarraf et al.’s study found a significant impact of self- results. It is noteworthy that in a study on self-stigmatization among
esteem on self-stigma in social psychological variables (47). patients with schizophrenia, it was highlighted that the side effects
Additionally, Jian et al. discovered that self-esteem moderates the of medication significantly impact self-stigma (55). Additionally,
association between self-stigma and suicide risk, indicating that other literature indicates a negative correlation between subjective
enhancing self-esteem can effectively reduce self-stigma (52). well-being and self-stigma, the stronger the sense of subjective well-
Coping styles are frequently discussed in the field of mental being, the lesser the self-stigma experienced (56, 57). In clinical
illness, and research has shown significant associations between treatment, focusing on self-esteem, coping styles, medication side
self-stigma, illness severity, and coping strategies in individuals with effects, and subjective well-being is crucial for intervening in
schizophrenia. The use of negative coping strategies increases self- self-stigma.
stigma in individuals with schizophrenia (45). Moreover, avoidance Based on the two aforementioned conclusions, we also
coping is negatively correlated with shame resistance, and reducing conducted an analysis on whether self-esteem, problem-solving
avoidance coping behaviors can effectively lower self-stigma (45, 53, coping style, and avoidance coping style have an indirect impact

TABLE 4 Explore which factors have the greatest influence on self-stigma.

Dependent Variable Predictors Beta T P

PANSS-P -0.13 -1.90 0.06

PANSS-N 0.08 1.26 0.21

ISMI
(F = 5.17) PANSS-G -0.10 -1.46 0.15
(P = 0.000b)
SEI -0.17 -2.11 0.04*

CQSP-PS -0.44 -2.58 0.01*

CQSP-A 0.39 4.65 0.00*

CQSP-CA 0.17 1.07 0.29

CQSP-ER 0.14 1.34 0.18

SSRS-O -0.05 -0.70 0.49

SSRS-S 0.02 0.19 0.85

SSRS-U -0.02 -0.24 0.81

CD-RISC-F1 0.10 0.86 0.40

CD-RISC-F2 0.06 0.51 0.61

CD-RISC-F3 -0.05 -0.52 0.60

CD-RISC-F4 0.04 0.48 0.63

CD-RISC-F5 -0.10 -1.18 0.24

ISMI, Internalized Stigma of Mental Illness; PANSS-P, Positive and Negative Syndrome Scale (Positive syndrome ); PANSS-N, Positive and Negative Syndrome Scale (Negative syndrome);
PANSS-G, Positive and Negative Syndrome Scale (General psychopathology); SEI, Self-esteem Inventor; CQSP-PS, Coping Questionnaire for Schizophrenic Patients (Problem Solving); CQSP-A,
Coping Questionnaire for Schizophrenic Patients (Avoidance); CQSP-CA, Coping Questionnaire for Schizophrenic Patients (Cognitive Adjustment); CQSP-ER, Coping Questionnaire for
Schizophrenic Patients (Emotion Regulation); SSSRS-O, Social Skills Rating Scale (Objective support) ; SSRS-S, Social Skills Rating Scale (Subjective support) ; SSRS-U, Social Skills Rating Scale
(Utilization of support); CD-RISC-F1, Connor-Davidson Resilience Scale (Adversity); CD-RISC-F2, Connor-Davidson Resilience Scale (Persistence); CD-RISC-F3, Connor-Davidson Resilience
Scale (Adaptability); CD-RISC-F4, Connor-Davidson Resilience Scale (Positive Acceptance); CD-RISC-F5, Connor-Davidson Resilience Scale (Secure Relationships). * p < 0.05.

Frontiers in Psychiatry 06 frontiersin.org

Liu et al. 10.3389/fpsyt.2024.1366030

avoidance and self-stigma, forming a vicious cycle (59, 60). Cavelti

et al.’s study also demonstrated that lower scores on avoidance are
associated with lower self-stigma and higher quality of life (61).
Therefore, we have found that there are many factors influencing
the quality of life of individuals with schizophrenia, and it is a complex
process. Self-stigma is an important factor that not only directly affects
quality of life but also serves as a mediator influencing quality of life.
According to the World Health Organization’s 2017 Mental
Health Atlas, the proportion of new admissions to long-term
hospitalizations (1 year or longer) has decreased to approximately
FIGURE 1 12% (62). However, over two-thirds of psychiatric patients have an
The mediating role of self-stigma in the relationship between self-
overall hospitalization duration exceeding 1 year (63). Some studies
esteem and quality of life.
suggest that self-stigma may be one of the reasons for long-term
hospitalization (26, 64). Our research findings indicate that self-
on quality of life via self-stigma. First, the research findings indicate stigma significantly affects quality of life, with self-esteem and
that the problem-solving coping style affects quality of life via self- coping strategies—particularly problem-solving and avoidance—
stigma, with a significant full mediating effect. However, the having a significant impact on self-stigma. This aligns with the
problem-solving coping style does not have a direct impact on findings of Huang et al., where self-esteem plays an important
quality of life; its influence is primarily mediated by self-stigma. mediating role between self-stigma and quality of life (65). A cross-
Holubova et al.’s study revealed that quality of life is primarily sectional study also revealed the relationship among self-stigma,
influenced by self-stigma and negative coping styles. Using coping methods, and quality of life (45).
structural equation modeling, they analyzed the interrelationships Based on these findings, it is suggested that clinical
between these factors and found that self-stigma serves as the main interventions should focus on reducing self-stigma, particularly by
contributing factor (45). From a reverse mediation perspective, our enhancing self-esteem and promoting adaptive coping strategies.
research results are consistent with numerous previous studies, Moreover, strategies worth considering include reducing public
indicating that higher levels of problem solving are associated with stigma (66), targeted psychoeducation (67), cognitive
lower self-stigma and higher quality of life (19, 54, 58). restructuring techniques in cognitive-behavioral therapy, and
Next, another result shows that avoidant coping strategies can increasing well-being (68–70), all aimed at improving self-stigma
directly impact quality of life and, at the same time, partially influence and quality of life for long-term hospitalized patients.
it via self-stigma. There is a reciprocal causal relationship between

5 Limitations
A
There are several limitations to this study. First, the cross-
sectional design of this study has inherent general and specific
limitations. As our patients were evaluated at only one time point,
the accuracy over time cannot be ensured. Second, the participants
were all from the same psychiatric hospital in Beijing, China, which
limits the generalizability of the study to the entire Chinese
mainland. The theoretical model may change or expand if
participants from other cities, regions, countries, or ethnic groups
are included. In addition, the sample size of this study was only 170
individuals with schizophrenia, which may have limited the
B generalizability of the research findings.

6 Conclusion
The self-stigma experienced by individuals with schizophrenia
significantly impacts their quality of life. Common factors influencing
self-stigma are self-esteem and coping strategies. Both self-esteem and
coping strategies directly or indirectly affect quality of life via self-
stigma. We recommend that clinical efforts to improve the quality of
FIGURE 2
The mediating role of self-stigma in the relationship coping styles
life for individuals with schizophrenia should focus on self-stigma
and quality of life. and its subfactors, particularly by addressing the mediating role of
self-stigma and examining the impact of self-esteem and coping

Frontiers in Psychiatry 07 frontiersin.org

Liu et al. 10.3389/fpsyt.2024.1366030

strategies on quality of life. Strategies such as enhancing self-esteem Visualization, Writing – original draft. WH: Formal analysis,
and modifying communication styles can be employed to reduce self- Validation, Writing – review & editing. HW: Investigation,
stigma and enhance quality of life. Software, Supervision, Validation, Writing – original draft. LL:
Funding acquisition, Methodology, Supervision, Writing – review
& editing. JC: Conceptualization, Data curation, Formal analysis,
7 Future research directions Investigation, Writing – review & editing. YL: Conceptualization,
Data curation, Formal analysis, Funding acquisition, Investigation,
This study has discussed the relationship between self-stigma and Methodology, Project administration, Resources, Software,
quality of life in patients with schizophrenia, as well as the mediating Supervision, Validation, Visualization, Writing – original draft,
role of self-stigma. It is well-known that schizophrenia frequently co- Writing – review & editing.
occurs with other mental disorders or certain psychiatric symptoms.
Research on autism symptoms in schizophrenia—specifically, their
effects on internalized shame, well-being, and clinical and functional Funding
characteristics—suggests that symptoms of autism spectrum
disorders may act protectively against self-stigma. Therefore, future The author(s) declare financial support was received for the
research could more broadly investigate the impacts of self-stigma, research, authorship, and/or publication of this article. This
considering the comorbidity of schizophrenia with other conditions. research was funded by the Beijing Huilongguan Fund and the
Longyue Plan Research Support Project of Beijing Huilongguan
Hospital, with the approved grant number QMS20222011.
Data availability statement Additionally, it received support from the Beijing Municipal
Administration of Hospitals' Youth Program under Grant
The original contributions presented in the study are included
No. QML20232006.
in the article/supplementary material, further inquiries can be
directed to the corresponding author/s.

Conflict of interest
Ethics statement The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be
This study involving human participants was reviewed and
construed as a potential conflict of interest.
approved by the Ethics Committee of Beijing Huilongguan Hospital,
with the approval number: 202324. The patients/participants provided
their written informed consent to participate in this study.
Publisher’s note
Author contributions All claims expressed in this article are solely those of the authors
and do not necessarily represent those of their affiliated organizations,
FL: Data curation, Methodology, Resources, Writing – original or those of the publisher, the editors and the reviewers. Any product
draft. HD: Data curation, Formal analysis, Writing – review & that may be evaluated in this article, or claim that may be made by its
editing. NH: Conceptualization, Project administration, Validation, manufacturer, is not guaranteed or endorsed by the publisher.

References
1. Štrkalj-Ivezić S. Stigma in clinical practice. Psychiatr Danub. (2013) 25 Suppl 2:S200–2. 7. Moges S, Belete T, Mekonen T, Menberu M. Lifetime relapse and its associated
2. Corrigan PW, Watson AC, Barr L. The self–stigma of mental illness: Implications for self– factors among people with schizophrenia spectrum disorders who are on follow up
esteem and self–efficacy. J Soc Clin Psychol. (2006) 25:875–84. doi: 10.1521/jscp.2006.25.8.875 at Comprehensive Specialized Hospitals in Amhara region, Ethiopia: a cross-
sectional study. Int J Ment Health Syst. (2021) 15:42. doi: 10.1186/s13033-021-
3. Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Rusch N. Challenging the public 00464-0
stigma of mental illness: a meta-analysis of outcome studies. Psychiatr Serv. (2012)
8. Morgades-Bamba CI, Fuster-Ruizdeapodaca MJ, Molero F. The impact of
63:963–73. doi: 10.1176/appi.ps.201100529 internalized stigma on the well-being of people with Schizophrenia. Psychiatry Res.
4. Tuaf H, Orkibi H. Community-based rehabilitation programme for adolescents (2019) 271:621–7. doi: 10.1016/j.psychres.2018.12.060
with mental health conditions in Israel: a qualitative study protocol. BMJ Open. (2019) 9. Chan KKS, Fung WTW, Leung DCK, Tsui JKC. The impact of perceived and
9:e032809. doi: 10.1136/bmjopen-2019-032809 internalised stigma on clinical and functional recovery among people with mental
5. Mokhtarabadi S, Sharifi H, Rad AAR, Iranpour A, Dehghan M. Development and illness. Health Soc Care Community. (2022). doi: 10.1111/hsc.14047
validation of HIV/AIDS Stigma and Discrimination Scale in Southeast Iran: The 10. Lahera G, Gá lvez JL, Sá nchez P, Martı́nez-Roig M, Pé rez-Fuster J, Garcı́a-
general population viewpoint. J Int Assoc Providers AIDS Care (JIAPAC). (2020) Portilla P, et al. Functional recovery in patients with schizophrenia:
19:2325958220963601. doi: 10.1177/2325958220963601 recommendations from a panel of experts. BMC Psychiatry. (2018) 18:1–10.
6. van Der Lee AP, Hoogendoorn A, de Haan L, Beekman AT. Discontinuity of doi: 10.1186/s12888-018-1755-2
psychiatric care for patients with schizophrenia, relation to previous psychiatric care 11. Dubreucq J, Plasse J, Franck N. Self-stigma in serious mental illness: A
and practice variation between providers: a retrospective longitudinal cohort study. systematic review of frequency, correlates, and consequences. Schizophr Bull. (2021)
BMC Psychiatry. (2021) 21:1–10. doi: 10.1186/s12888-021-03319-7 47:1261–87. doi: 10.1093/schbul/sbaa181

Frontiers in Psychiatry 08 frontiersin.org

Liu et al. 10.3389/fpsyt.2024.1366030

12. Ben C, Chio FH, Mak WW, Corrigan PW, Chan KK. Internalization process of 36. Wilkinson G, Hesdon B, Wild D, Cookson R, Farina C, Sharma V, et al. Self-
stigma of people with mental illness across cultures: A meta-analytic structural report quality of life measure for people with schizophrenia: the SQLS. Br J Psychiatry.
equation modeling approach. Clin Psychol Rev. (2021) 87:102029. doi: 10.1016/ (2000) 177:42–6. doi: 10.1192/bjp.177.1.42
j.cpr.2021.102029 37. Isjanovski V, Naumovska A, Bonevski D, Novotni A. Validation of the
13. Kamaradova D, Latalova K, Prasko J, Kubinek R, Vrbova K, Mainerova B, et al. Schizophrenia Quality of Life Scale Revision 4 (SQLS-R4) among patients with
Connection between self-stigma, adherence to treatment, and discontinuation of schizophrenia. Open Access Macedonian J Med Sci. (2016) 4:65. doi: 10.3889/
medication. Patient preference adherence. (2016) p:1289–98. doi: 10.2147/PPA oamjms.2016.015
14. Yanos PT, Lysaker PH, Silverstein SM, Vayshenker B, Gonzales L, West ML, 38. Tong Y, Wang D, Cao Y. The factor structure of coping strategies in
et al. A randomized-controlled trial of treatment for self-stigma among persons schizophrenic patients. Chin J Nervous Ment Dis. (2006), 385–91.
diagnosed with schizophrenia-spectrum disorders. Soc Psychiatry Psychiatr 39. Tong Y, Wang D, An J. Reliability and validity of coping style questionnaire in
Epidemiol. (2019) 54:1363–78. doi: 10.1007/s00127-019-01702-0 schizophrenic patients. Chin J Clin Psychol. (2008) 16:135–7.
15. Maharjan S, Panthee B. Prevalence of self-stigma and its association with self- 40. Bavik YL, Shaw JD, Wang X-H. Social support: Multidisciplinary review, synthesis,
esteem among psychiatric patients in a Nepalese teaching hospital: A cross-sectional and future agenda. Acad Manage Ann. (2020) 14:726–58. doi: 10.5465/annals.2016.0148
study. BMC Psychiatry. (2019) 19:1–8. doi: 10.1186/s12888-019-2344-8
41. Malecki CK, Elliott SN. Adolescents’ ratings of perceived social support and its
16. Hawke LD, Parikh SV, Michalak EE. Stigma and bipolar disorder: a review of the importance: Validation of the Student Social Support Scale. Psychol Schools. (1999)
literature. J Affect Disord. (2013) 150:181–91. doi: 10.1016/j.jad.2013.05.030 36:473–83. doi: 10.1002/(SICI)1520-6807(199911)36:6<473::AID-PITS3>3.0.CO;2-0
17. Gerlinger G, Hauser M, De Hert M, Lacluyse K, Wampers M, Correll CU. 42. Leucht S, Samara M, Heres S, Patel MX, Furukawa T, Cipriani A, et al. Dose
Personal stigma in schizophrenia spectrum disorders: a systematic review of prevalence equivalents for second-generation antipsychotic drugs: the classical mean dose method.
rates, correlates, impact and interventions. World Psychiatry. (2013) 12:155–64. Schizophr Bull. (2015) 41:1397–402. doi: 10.1093/schbul/sbv037
doi: 10.1002/wps.20040
43. Chan KKS, Fung WTW. The impact of experienced discrimination and self-
18. Vrbova K, Prasko J, Ociskova M, Kamaradova D, Marackova M, Holubova M, stigma on sleep and health-related quality of life among individuals with mental
et al. Quality of life, self-stigma, and hope in schizophrenia spectrum disorders: a cross- disorders in Hong Kong. Qual Life Res. (2019) 28:2171–82. doi: 10.1007/s11136-019-
sectional study. Neuropsychiatr Dis Treat. (2017), 567–76. doi: 10.2147/NDT 02181-1
19. Xu Z-Y, Zu S, Xiang Y-T, Wang N, Guo Z-H, Kilbourne AM, et al. Associations 44. Caqueo-Urı́zar A, Boyer L, Urzú a A, Williams DR. Self-stigma in patients with
of self-esteem, dysfunctional beliefs and coping style with depression in patients with schizophrenia: a multicentric study from three Latin-America countries. Soc Psychiatry
schizophrenia: A preliminary survey. Psychiatry Res. (2013) 209:340–5. doi: 10.1016/ Psychiatr Epidemiol. (2019) 54:905–9. doi: 10.1007/s00127-019-01671-4
j.psychres.2013.02.012
45. Holubova M, Prasko J, Ociskova M, Kantor K, Vanek J, Slepecky M, et al. Quality
20. Corrigan PW, Rao D. On the self-stigma of mental illness: Stages, disclosure, and of life, self-stigma, and coping strategies in patients with neurotic spectrum disorders: a
strategies for change. Can J Psychiatry. (2012) 57:464–9. doi: 10.1177/ cross-sectional study. Psychol Res Behav Manage. (2019), 81–95. doi: 10.2147/PRBM
070674371205700804
46. Sarraf L, Lepage M, Sauvé G. The clinical and psychosocial correlates of self-
21. Ritsher JB, Otilingam PG, Grajales M. Internalized stigma of mental illness: stigma among people with schizophrenia spectrum disorders across cultures: a
psychometric properties of a new measure. Psychiatry Res. (2003) 121:31–49. systematic review and meta-analysis. Schizophr Res. (2022) 248:64–78. doi: 10.1016/
doi: 10.1016/j.psychres.2003.08.008 j.schres.2022.08.001
22. Yu W, Tong J, Sun X, Chen F, Zhang J, Pei Y, et al. Analysis of medication 47. Schwarzbold ML, Kern RS, Novacek DM, McGovern JE, Catalano LT, Green
adherence and its influencing factors in patients with schizophrenia in the Chinese MF. Self-stigma in psychotic disorders: Clinical, cognitive, and functional correlates in
institutional environment. Int J Environ Res Public Health. (2021) 18:4746. a diverse sample. Schizophr Res. (2021) 228:145–50. doi: 10.1016/j.schres.2020.12.003
doi: 10.3390/ijerph18094746
48. Oexle N, Waldmann T, Staiger T, Xu Z, Rüsch N. Mental illness stigma and
23. Hou M-r, Wang J, Xue J-h, Pei J-q, Shi Y, Li X-w. Gender differences among long- suicidality: the role of public and individual stigma. Epidemiol Psychiatr Sci. (2018)
stay inpatients with schizophrenia in China: A cross-sectional study. Heliyon. (2023) 9(5). 27:169–75. doi: 10.1017/S2045796016000949
doi: 10.1016/j.heliyon.2023.e15719
49. Vass V, Sitko K, West S, Bentall RP. How stigma gets under the skin: the role of
24. Chen J, Song H, Li S, Teng Z, Su Y, Chen J, et al. Social support and quality of life stigma, self-stigma and self-esteem in subjective recovery from psychosis. Psychosis.
among chronically homeless patients with schizophrenia. Front Psychiatry. (2022) (2017) 9:235–44. doi: 10.1080/17522439.2017.1300184
13:928960. doi: 10.3389/fpsyt.2022.928960
50. Mantovani N, Pizzolati M, Edge D. Exploring the relationship between stigma
25. Wang W-L, Zhou Y-Q, Chai N-N, Li G-H. Sleep disturbance and quality of life and help-seeking for mental illness in African-descended faith communities in the UK.
in clinically stable inpatients with schizophrenia in rural China. Qual Life Res. (2020) Health Expectations. (2017) 20:373–84. doi: 10.1111/hex.12464
29:2759–68. doi: 10.1007/s11136-020-02541-2
51. Pescosolido BA, Manago B, Monahan J. Evolving public views on the likelihood
26. Wang X-Q, Petrini M, Morisky DE. Comparison of the quality of life, perceived of violence from people with mental illness: stigma and its consequences. Health
stigma and medication adherence of Chinese with schizophrenia: A follow-up study. Affairs. (2019) 38:1735–43. doi: 10.1377/hlthaff.2019.00702
Arch Psychiatr Nurs. (2016) 30:41–6. doi: 10.1016/j.apnu.2015.10.006
52. Jian C-R, Wang P-W, Lin H-C, Huang M-F, Yeh Y-C, Liu T-L, et al. Association
27. Organization, W.H. The ICD-10 classification of mental and behavioural between self-stigma and suicide risk in individuals with schizophrenia: Moderating
disorders: diagnostic criteria for research Vol. 2. World Health Organization (1993). effects of self-esteem and perceived support from friends. Int J Environ Res Public
28. Keepers GA, Fochtmann LJ, Anzia JM, Benjamin S, Lyness JM, Mojtabai R, et al. Health. (2022) 19:15071. doi: 10.3390/ijerph192215071
The American Psychiatric Association practice guideline for the treatment of patients 53. O’Connor LK, Yanos PT, Firmin RL. Correlates and moderators of stigma
with schizophrenia. Am J Psychiatry. (2020) 177:868–72. doi: 10.1176/ resistance among people with severe mental illness. Psychiatry Res. (2018) 270:198–204.
appi.books.9780890424841 doi: 10.1016/j.psychres.2018.09.040
29. Lancon C, Auquier P, Nayt G, Reine G. Stability of the five-factor structure of the 54. Riebel M, Rohmer O, Charles E, Lefebvre F, Weibel S, Weiner L. Compassion-
Positive and Negative Syndrome Scale (PANSS). Schizophr Res. (2000) 42:231–9. focused therapy (CFT) for the reduction of the self-stigma of mental disorders: the
doi: 10.1016/S0920-9964(99)00129-2 COMpassion for Psychiatric disorders, Autism and Self-Stigma (COMPASS) study
30. Casale S, Fioravanti G, Benucci SB, Falone A, Ricca V, Rotella F. A meta-analysis on the protocol for a randomized controlled study. Trials. (2023) 24:1–20. doi: 10.1186/
association between self-esteem and problematic smartphone use. Comput Hum Behav. s13063-023-07393-y
(2022), 107302. doi: 10.1016/j.chb.2022.107302 55. Barlati S, Morena D, Nibbio G, Cacciani P, Corsini P, Mosca A, et al. Internalized
31. Onen AS, Ulusoy FM. The relationship between pre-service teachers’ self-esteem stigma among people with schizophrenia: Relationship with socio-demographic,
and emotional intelligence levels. Procedia-Social Behav Sci. (2015) 186:1163–8. clinical and medication-related features. Schizophr Res. (2022) 243:364–71.
doi: 10.1016/j.sbspro.2015.04.195 doi: 10.1016/j.schres.2021.06.007
32. Taylor S. The psychology of pandemics. Annu Rev Clin Psychol. (2022) 18:581– 56. Pé rez-Garı́n D, Molero F, Bos AE. Internalized mental illness stigma and
609. doi: 10.1146/annurev-clinpsy-072720-020131 subjective well-being: The mediating role of psychological well-being. Psychiatry Res.
33. Cheng C, Dong D, He J, Zhong X, Yao S. Psychometric properties of the 10-item (2015) 228:325–31. doi: 10.1016/j.psychres.2015.06.029
Connor–Davidson Resilience Scale (CD-RISC-10) in Chinese undergraduates and depressive 57. Magallares A, Perez-Garin D, Molero F. Social Stigma and well-being in a sample
patients. J Affect Disord. (2020) 261:211–20. doi: 10.1016/j.jad.2019.10.018 of schizophrenia patients. Clin Schizophr related psychoses. (2016) 10:51–7.
doi: 10.3371/csrp.MAPE.043013
34. Mucci A, Galderisi S, Gibertoni D, Rossi A, Rocca P, Bertolino A, et al. Factors
associated with real-life functioning in persons with schizophrenia in a 4-year follow- 58. Ahmed S, Mé ndez RY, Naveed S, Akhter S, Mushtaque I, Malik MA, et al.
up study of the Italian network for research on psychoses. JAMA Psychiatry. (2021) Assessment of hepatitis-related knowledge, attitudes, and practices on quality of life
78:550–9. doi: 10.1001/jamapsychiatry.2020.4614 with the moderating role of internalized stigma among hepatitis B-positive patients in
Pakistan. Health Psychol Behav Med. (2023) 11:2192782. doi: 10.1080/
35. Chang C-C, Wu T-H, Chen C-Y, Wang J-D, Lin C-Y. Psychometric evaluation
21642850.2023.2192782
of the internalized stigma of mental illness scale for patients with mental illnesses:
measurement invariance across time. PloS One. (2014) 9:e98767. doi: 10.1371/ 59. Hormazá bal-Salgado R, Poblete-Troncoso M. Living with bipolar disorder in Chile:
journal.pone.0098767 A qualitative study. Int J Ment Health Nurs. (2020) 29:488–97. doi: 10.1111/inm.12686

Frontiers in Psychiatry 09 frontiersin.org

Liu et al. 10.3389/fpsyt.2024.1366030

60. Qin S. How Does Self-Stigma Influence Functionality in People with Serious retrospectively longitudinal study. J Pacific Rim Psychol. (2018) 12:e10.
Mental Illness? A Multiple Mediation Model of “Why-Try” Effect, Coping Resources, and doi: 10.1017/prp.2017.18
Personal Recovery. Illinois Institute of Technology (2022). 66. Chen ES, Chang WC, Hui CL, Chan SK, Lee EHM, Chen EY. Self-stigma and
61. Cavelti M, Kvrgic S, Beck E-M, Rüsch N, Vauth R. Self-stigma and its affiliate stigma in first-episode psychosis patients and their caregivers. Soc Psychiatry
relationship with insight, demoralization, and clinical outcome among people with Psychiatr Epidemiol. (2016) 51:1225–31. doi: 10.1007/s00127-016-1221-8
schizophrenia spectrum disorders. Compr Psychiatry. (2012) 53:468–79. doi: 10.1016/ 67. Yanos PT, Lucksted A, Drapalski AL, Roe D, Lysaker P. Interventions targeting
j.comppsych.2011.08.001 mental health self-stigma: A review and comparison. Psychiatr Rehabil J. (2015) 38:171.
62. Jaeschke K, Hanna F, Ali S, Chowdhary N, Dua T, Charlson F. Global estimates doi: 10.1037/prj0000100
of service coverage for severe mental disorders: findings from the WHO Mental Health 68. Young DK-W. Cognitive behavioral therapy group for reducing self-stigma for
Atlas 2017. Global Ment Health. (2021) 8:e27. doi: 10.1017/gmh.2021.19 people with mental illness. Res Soc work Pract. (2018) 28:827–37. doi: 10.1177/
63. Okayama T, Usuda K, Okazaki E, Yamanouchi Y. Number of long-term 1049731516681849
inpatients in Japanese psychiatric care beds: trend analysis from the patient survey 69. Ç apar Ç iftçi M, Kavak Budak F. The effect of cognitive behavioral therapy-based
and the 630 survey. BMC Psychiatry. (2020) 20:1–8. doi: 10.1186/s12888-020-02927-z psychoeducation on internalized stigma and functional remission in individuals
64. Ho RWH, Chang WC, Kwong VWY, Lau ESK, Chan GHK, Jim OTT, et al. diagnosed with schizophrenia. Perspect Psychiatr Care. (2022) 58:2170–82.
Prediction of self-stigma in early psychosis: 3-year follow-up of the randomized- doi: 10.1111/ppc.13044
controlled trial on extended early intervention. Schizophr Res. (2018) 195:463–8. 70. Horsselenberg EM, van Busschbach JT, Aleman A, Pijnenborg GH. Self-stigma
doi: 10.1016/j.schres.2017.09.004 and its relationship with victimization, psychotic symptoms and self-esteem among
65. Huang W-Y, Chen S-P, Pakpour AH, Lin C-Y. The mediation role of self- people with schizophrenia spectrum disorders. PloS One. (2016) 11:e0149763.
esteem for self-stigma on quality of life for people with schizophrenia: A doi: 10.1371/journal.pone.0149763

Frontiers in Psychiatry 10 frontiersin.org