Correlates of internalized stigma levels in people with psychosis in the Czech Republic

Abstract

Background:

Internalized stigma negatively affects lives and prognosis of individuals with psychosis.

Aim:

This study aimed to identify correlates of internalized stigma among individuals with psychosis in a sample of community care users in the Czech Republic.

Methods:

A cross-sectional study was conducted among 133 community service users with psychosis. A shortened version of the Internalized Stigma of Mental Illness (ISMI-10) scale was used alongside the 5-level EQ-5D version (EQ-5D-5L), assessing health-related quality of life. Descriptive and linear regression analyses were performed in order to determine levels of internalized stigma and its correlates.

Results:

High levels of internalized stigma were reported in 25% of participants. Lower internalized stigma levels were associated with better self-reported health status and being married, and higher internalized stigma with a longer period of time since initial contact with psychiatric care.

Conclusion:

Lower internalized stigma levels are associated with better self-reported health-related quality of life. In addition, clients having used psychiatric care for longer periods of time reported significantly higher internalized stigma levels. Therefore, authors suggest self-stigma reduction interventions based in a community setting with an emphasis on targeting clients with chronic psychosis.

Keywords

Internalized stigma correlates psychosis community care setting CZEPOS

Introduction

Stigma has a substantial impact on various facets of life for people with mental illness. A large body of literature focuses on public stigma and its reduction, but much has discounted internalized stigma and the role it plays in the lives of individuals with psychosis. Internalized stigma (also referred to as personal stigma or self-stigma) is defined as the endorsement and internalization of negative stereotypes and prejudices associated with mental illness in persons with mental health conditions (Corrigan & Watson, 2002).

Prevalence rates for internalized stigma for people with mental illness vary and are difficult to compare due to inconsistencies in metrics used and populations assessed (Link, Yang, Phelan, & Collins, 2004). International prevalence rates of internalized stigma for individuals with psychosis range from 18.8% to 44.2% (Drapalski et al., 2013; Lv, Wolf, & Wang, 2013; Mosanya, Adelufosi, Adebowale, Ogunwale, & Adebayo, 2014; Werner, Aviv, & Barak, 2008), and within Europe, 33% to 41.7% of patients with psychosis have moderate-to-high levels of internalized stigma (Brohan, Elgie, Sartorius, & Thornicroft, 2010; Krajewski, Burazeri, & Brand, 2013). Research indicates that prevalence rates of internalized stigma can be greater in patients living with psychosis than in patients with non-psychotic mental illness (Lien et al., 2015). While a recent study found no significant variance between internalized stigma levels and various demographic variables in patients with psychosis (Vrbová et al., 2015), one systematic review detected marginal associations among patient sociodemographic variables and levels of internalized stigma, reporting a significant association between literacy rates and internalized stigma (Gerlinger et al., 2013).

The quality of life and mental health of people with psychosis is significantly poorer for individuals with internalized stigma (Chan & Mak, 2014; Holubova et al., 2016; Mashiach-Eizenberg, Hasson-Ohayon, Yanos, Lysaker, & Roe, 2013; Park, Bennett, Couture, & Blanchard, 2013; Tang & Wu, 2012), and this trend persists regardless of patient demographics (Mosanya et al., 2014). Consequences of internalized stigma in patients with psychosis include decreased social functioning (Gerlinger et al., 2013; Hill & Startup, 2013; Lysaker, Davis, Warman, Strasburger, & Beattie, 2007; Yanos, Roe, Markus, & Lysaker, 2008), activity levels (Moriarty, Jolley, Callanan, & Garety, 2012), social power (Campellone, Caponigro, & Kring, 2014), vocational functioning (Gerlinger et al., 2013; Yanos, Lysaker, & Roe, 2010), self-esteem (Mashiach-Eizenberg et al., 2013; Staring, Van der Gaag, Van den Berge, Duivenvoorden, & Mulder, 2009; Yanos et al., 2008), self-efficacy (Hill & Startup, 2013), as well as increased depressive symptoms (Lien et al., 2015; Park et al., 2013; Schrank, Amering, Hay, Weber, & Sibitz, 2014; Valiente, Provencio, Espinosa, Duque, & Everts, 2015; Yanos et al., 2008) and symptom severity (Chan & Mak, 2014; Holubova et al., 2016; Livingston, Rossiter, & Verdun-Jones, 2011; Lysaker et al., 2007). Finally, internalized stigma undermines treatment adherence (Fung, Tsang, & Chan, 2010; Gerlinger et al., 2013; Kvrgic, Cavelti, Beck, Rüsch, & Vauth, 2013; Tsang, 2013; Tsang, Fung, & Chung, 2010; Uhlmann et al., 2014; Vrbová et al., 2014), acts as a barrier to help-seeking (Anderson, Fuhrer, & Malla, 2013) and contributes significantly to a greater psychosocial impact of stigma when receiving psychiatric treatment (Świtaj, Chrostek, Grygiel, Wciórka, & Anczewska, 2016).

Studies clarifying the relationships between sociodemographic characteristics and stages of illness for patients with internalized stigma lack, yet they are fundamental to the successful design and implementation of effective stigma reduction interventions (Gerlinger et al., 2013). We aimed to identify correlates of internalized stigma among people with psychosis in a sample of community care users in the Czech Republic in order to identify risk factors which should be taken into account when designing self-stigma interventions.

Methods

Participants and study design

This cross-sectional study was nested into a year-long longitudinal study (Kondrátová, König, Mladá, & Winkler, 2019; Winkler et al., 2018) measuring the cost and outcomes of psychosis. Data were collected during the second measurement, out of four conducted within the study.

Data were collected in fall of 2015 within the eight community mental health care centres throughout seven regions of the Czech Republic. Community mental health care is provided as a part of the social service scheme in the Czech Republic. Usually, community mental health care centres are non-governmental organizations providing one or more registered social services (e.g. social rehabilitation, social counselling and sheltered workshops). Eligible clients for this study were users with a psychotic disorder having used community care services for at least 3 months at the beginning of the study. Participants were randomly selected from all clients meeting the selection criteria in each centre. A total of 635 community service users met the inclusion criteria and were considered eligible for the study and were subsequently randomized. From the total number of respondents who were asked to participate in the study (N = 277), 139 refused to participate for various reasons: they were not in a good health status (N = 29), hospitalized (N = 26), doubted their confidentiality as participants in the study (N = 22) and others (such as length of study or not being interested in participating). There were no significant differences among the respondents and the eligible clients who refused to participate in the study in terms of age, gender, education, family status or years of service use with a particular provider. A total of 133 respondents participated in the second measurement as two were hospitalized, one moved to different city, one stopped using community care services and one decided not to take part in the study. Respondents were given a small amount of money for participating in each wave. Further information about the study may be found elsewhere (Winkler et al., 2018).

Measures

Internalized stigma was measured by a shortened version of the Internalized Stigma of Mental Illness (ISMI-10) scale (Boyd, Otilingam, & DeForge, 2014). Respondents rated eight negatively oriented and two positively oriented items according to a 4-point scale (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree). Mean scores were computed afterwards with a higher score indicating higher internalized stigma (if one item had missing value, a score was computed from nine items; in the case of additional missing values, a score was not computed). Scores above 2.5 are considered as high internalized stigma (Ritsher & Phelan, 2004). Cronbach’s alpha tested at .71, indicating good reliability of the scale in this survey. The psychometric properties of the Czech version are satisfactory (Ociskova, Prasko, Kamaradova, Grambal, & Sigmundova, 2015; Vrbová et al., 2016). The ISMI scale is self-reported.

Health-related quality-of-life score was assessed by a standardized measurement tool, 5-level EQ-5D version (EQ-5D-5L), consisting of five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. These domains are evaluated on five levels: no problems, slight problems, moderate problems, severe problems and extreme problems (Herdman et al., 2011).

The questionnaire also consisted of sociodemographic variables (gender, age, education, family status, economic activity and income) and health-related variables (age of initial contact with psychiatric care, number of months since last hospitalization and attitudes towards medication).

Statistical analysis

Descriptive and linear regression analyses were performed in IBM SPSS Statistics 23. A mean score was measured for each ISMI item as well as the ISMI scale. A multiple linear regression model was created in order to identify correlates of internalized stigma as measured by the ISMI scale. For assessing multicollinearity, we checked the tolerance and variance inflation factor (VIF). If otherwise not specified, in all analyses, p-values less than .05 were considered statistically significant. Analysed variables include sociodemographic characteristics, economic activity, health status and psychiatric history of patients.

Results

Participants

The sample consisted of 133 community care users with experience of psychosis. Their sociodemographic and health characteristics are shown in Table 1.

Table 1.

Characteristics of respondents (N = 133).

		N	%
Gender	Male	70	52.6
Gender	Female	63	47.4
Age (years)	18–34	39	29.3
	35–49	60	45.1
	50+	34	25.6
Education^a	Primary	22	16.7
	Lower secondary	43	32.6
	Upper secondary	54	40.9
	University	13	9.8
Family status	Single	80	60.9
	In relationship	15	11.3
	Married	12	9.0
	Divorced	25	18.0
	Widowed	1	0.8
Economic activity	No	76	57.1
Economic activity	Yes	57	42.9
Previous hospitalization	Never	5	3.8
Previous hospitalization	Yes	128	96.2
		M
Time since initial contact with care (years)		17.7
Total		133	100

One participant did not fill in the answer.

Outcomes

Table 2 shows the mean ISMI score of internalized stigma among participants (2.27; confidence interval (CI): 2.20–2.36). According to the two-category interpretation of the ISMI score of Ritsher and Phelan (2004), there are not overall high rates of internalized stigma in this population. However, the prevalence of high internalized stigma scores among participants was 25.0%.

Table 2.

Characteristics of ISMI score.

	M	Confidence interval		Minimum	Maximum	Prevalence of high internalized stigma (score > 2.5)
	M	Lower	Upper	Minimum	Maximum	Prevalence of high internalized stigma (score > 2.5)
ISMI score	2.27	2.20	2.36	1.1	3.5	25.0%

If we look closer at the items which constitute the ISMI score (Table 3), we can see that the highest mean answer and the highest percentage of more stigmatizing answers include the following items: ‘Having a mental illness has spoiled my life’ (M = 2.76; % of more stigmatizing answers = 60.2) and ‘People without mental illness could not possibly understand me’ (M = 2.55; % of more stigmatizing answers = 50.4). All other items have a mean answer lower than 2.5, with the lowest mean answer 1.83 for the item ‘Mentally ill people tend to be violent’ (% of more stigmatizing answers = 18.0).

Table 3.

Mean answers and percentages of answer to ISMI items.

	Mean answer	Standard deviation	Less stigmatizing answer		More stigmatizing answer
	Mean answer	Standard deviation	N	%	N	%
Mentally ill people tend to be violent.	1.83	0.79	109	82.0	24	18.0
People with mental illness make important contributions to society.	2.42	0.77	74	56.1	58	43.9
I don’t socialize as much as I used to because my mental illness might make me look or behave ‘weird’.	2.33	0.97	73	55.3	59	44.7
Having a mental illness has spoiled my life.	2.76	0.91	53	39.8	80	60.2
I stay away from social situations in order to protect my family or friends from embarrassment.	1.95	0.80	102	77.9	29	22.1
People without mental illness could not possibly understand me.	2.55	0.96	66	49.6	67	50.4
People ignore me or take me less seriously just because I have a mental illness.	2.39	0.82	76	57.6	56	42.4
I can’t contribute anything to society because I have a mental illness.	2.08	0.83	94	71.2	38	28.8
I can have a good, fulfilling life, despite my mental illness.	2.11	0.88	99	75.0	33	25.0
Others think that I can’t achieve much in life because I have a mental illness.	2.27	0.85	78	59.1	54	40.9

Not all respondents answered all items.

The linear regression model created for the identification of internalized stigma predictors is presented in Table 4. The ISMI score was set as a dependent variable. Independent variables were gender, age, education, family status, economic activity and first contact with psychiatric care and health status. Results show that lower internalized stigma levels were associated with better health status (unstandardized beta coefficient (β) = –0.010, p = < .001) and being married (unstandardized beta coefficient (β) = –0.272, p = .032). Higher internalized stigma levels were associated with a longer period of time since initial contact with psychiatric care (unstandardized beta coefficient (β) = 0.010, p = .019). The model accounted for 23.1% of sample variation (adjusted R² = .231).

Table 4.

Linear regression model for ISMI score.

		Unstandardized coefficients		Standardized coefficients	t	Significance
		β	SE	β	t	Significance
Constant	x	2.749	0.176		15.625	.000
Gender	Male	Ref.
Gender	Female	0.056	0.070	0.071	0.791	.431
Age (years)	18–34	Ref.
	35–49	0.138	0.089	0.176	1.545	.125
	50+	0.120	0.124	0.132	0.963	.338
Education	Primary school	Ref.
	Lower secondary	−0.035	0.099	−0.043	−0.355	.723
	Upper secondary	0.015	0.098	0.019	0.153	.879
	University	0.025	0.125	0.021	0.198	.844
Family status	Single	Ref.
	Partner	0.094	0.106	0.079	0.884	.379
	Married	−0.272	0.125	−0.199	−2.174	.032
	Divorced	−0.131	0.097	−0.131	−1.347	.181
	Widowed	−0.504	0.379	−0.116	−1.329	.187
Economic activity	No	Ref.
Economic activity	Yes	−0.056	0.070	−0.071	−0.804	.423
Time since initial contact with psychiatric care (years)	x	0.010	0.004	0.257	2.388	.019
Health-related quality-of-life score	x	−0.010	0.002	−0.417	−4.980	<.001
Adjusted R²		.231

Note: Bold p-values indicate results significant on the level of 0.05.

Discussion

Our results indicate that overall levels of internalized stigma are not exceptionally high in community service users with psychosis in the Czech Republic. Still, 25.0% reached ISMI score higher than 2.5, indicating moderate-to-high levels of internalized stigma. Similar studies conducted in community-based service users with psychosis report more prevalent rates of moderate-to-high ISMI scores, such as in Hong Kong (38.3%) and Guangzhou, China (49.5%) (Young & Ng, 2016), as well as in psychiatric out-patients in Ethiopia (46.7%) (Assefa, Shibre, Asher, & Fekadu, 2012). In a cross-sectional study of persons with mental illness across six countries in Europe, the distribution of moderate-to-high levels of ISMI scores was 33%, ranging from 15% in Sweden to 57% in Croatia (Krajewski et al., 2013). In the United States, 36.1% of people with a severe mental illness showed higher levels of self-stigma (West, Yanos, Smith, Roe, & Lysaker, 2011). As many studies examining internalized stigma included more broad populations of people with mental illness, our results are relatively low when considering the findings from past research show that patients with psychosis can have higher levels of self-stigma in comparison with patients with other mental illnesses (Lien et al., 2015). Past studies in the Czech Republic report exponentially higher rates of self-stigma for in-patients (63.2%; Grambal et al., 2016) and for out-patients with schizophrenia (64.0%; Holubova et al., 2016).

Apart from methodological reasons, the differences between in-patients and individuals using community services could be explained by the type of care they receive. It could be hypothesized that people using community care centres are in more stable health conditions, feel less excluded from society and have more social contacts than those hospitalized in in-patient care. However, half of the respondents agreed with the item ‘People without mental illness could not possibly understand me’ which could indicate that the socialization in community services is mostly among people with experience of mental illness and those people lack contact with the ‘healthy’ population. A comparison of samples from out-patient and community services and eventually those who do not use any service would be needed to explain the role of types of mental health care on self-stigma of people with mental illness.

A longer time since the initial contact with psychiatric care is associated with higher internalized stigma. Studies have identified several factors that can lead to change in self-stigma from a long-term perspective. Lysaker, Roe, Ringer, Gilmore, and Yanos (2012) studied whether participation in rehabilitation is linked to declines in self-stigma, finding that decreases in self-stigma may be correlated with increased self-esteem, while higher levels of emotional distress may be a barrier to self-stigma reduction. Another study focused on people with severe mental illness found out that a change in self-stigma was significantly negatively related to change in social functioning (Yanos et al., 2012). It would be beneficial to study how psychiatric care (various types of care) contributes to factors such as self-esteem and emotional distress to be able to explain this outcome of our study.

Our analysis showed better health status, being married and a shorter period of time since initial contact with psychiatric care as predictors of internalized stigma levels. The evidence surrounding these correlates is mixed. A study conducted in the Czech Republic found no statistically significant differences in mean self-stigma levels between out-patient groups according to marital status, but however found strong statistically significant differences in self-stigma levels between patients with a partner, and without a partner (Grambal et al., 2016), an association that the findings from the current study does not support. Another study conducted in Ethiopia found that single marital status was significantly associated with higher ISMI scores in psychiatric out-patients (Assefa et al., 2012). The conflicting and limited understanding of internalized stigma and its association with marital status as well as partnership status will require further investigation to understand nuances surrounding the effects of patients’ personal relationships and levels of internalized stigma. There are also variables indicated as correlates of self-stigma identified through past research, which were not found significant in our population. For example, in European countries, significant predictors of higher ISMI scores included age group (50–59 years old), economic activity, lower number of social contacts, and lower self-efficacy/self-esteem and sense of power/powerlessness (Krajewski et al., 2013).

However, there are some limitations to this study. First, our results are not generalizable to all people who experiences episode(s) of psychosis since our sample consists only of community care users having spent a long time in psychiatric services (17.7 years on average). There is a possibility that prevalence and correlates of internalized stigma will be different within institutionalized patients or out-patients. Second, some relevant variables were not collected due to the fact that this study did not primarily focus on internalized stigma. Such variables are influenced by internalized stigma, including self-esteem, as well as current symptoms of psychosis which have been indicated as important predictors in past research (Aakre, Klingaman, & Docherty, 2015). Nevertheless, the robust sample size and randomized sampling of the current study contribute important findings in the context of Eastern Europe where studies with such methodology are scarce and provides interesting results relevant to self-stigma within community care settings.

In conclusion, approximately 25% of community care users reported high levels of self-stigma. With the aim of increasing the overall positive impact of community care settings in the Czech Republic, screening could be used to detect and target this sub-population for self-stigma reduction interventions in order to increase social and vocational functioning, activity levels, social power, self-esteem, self-efficacy, treatment adherence and help-seeking, while decreasing depressive symptoms and symptom severity.

Footnotes

Acknowledgements

The authors are grateful to all respondents as well as to those who collected the data.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is a result of the research funded by the project no. LO1611 with financial support from the MEYS under the NPU-I programme.

ORCID iDs

Aneta Alexová

Anna Kågström

Lucie Kondrátová

References

Aakre

J. M.

Klingaman

E. A.

Docherty

N. M.

(2015). The relationship between stigma sentiments and self-identity of individuals with schizophrenia. Psychiatric Rehabilitation Journal, 38, 125–131.

Anderson

K. K.

Fuhrer

Malla

A. K.

(2013). ‘There are too many steps before you get to where you need to be’: Help-seeking by patients with first-episode psychosis. Journal of Mental Health, 22, 384–395.

Assefa

Shibre

Asher

Fekadu

(2012). Internalized stigma among patients with schizophrenia in Ethiopia: A cross-sectional facility-based study. BMC Psychiatry, 12, 239.

Boyd

J. E.

Otilingam

P. G.

DeForge

B. R.

(2014). Brief version of the internalized stigma of mental illness (ISMI) scale: Psychometric properties and relationship to depression, self esteem, recovery orientation, empowerment, and perceived devaluation and discrimination. Psychiatric Rehabilitation Journal, 37, 17–23.

Brohan

Elgie

Sartorius

Thornicroft

(2010). Self-stigma, empowerment and perceived discrimination among people with schizophrenia in 14 European countries: The GAMIAN-Europe study. Schizophrenia Research, 122, 232–238.

Campellone

T. R.

Caponigro

J. M.

Kring

A. M.

(2014). The power to resist: The relationship between power, stigma, and negative symptoms in schizophrenia. Psychiatry Research, 215, 280–285.

Chan

K. K. S.

Mak

W. W. S.

(2014). The mediating role of self-stigma and unmet needs on the recovery of people with schizophrenia living in the community. Quality of Life Research, 23, 2559–2568.

Corrigan

P. W.

Watson

A. C.

(2002). The paradox of self-stigma and mental illness. Clinical Psychology: Science and Practice, 91, 35:53.

Drapalski

A. L.

Lucksted

Perrin

P. B.

Aakre

J. M.

Brown

C. H.

DeForge

B. R.

… Boyd

J. E.

(2013). A model of internalized stigma and its effects on people with mental illness. Psychiatric Services, 64, 264–269.

10.

Fung

K. M. T.

Tsang

H. W. H.

Chan

(2010). Self-stigma, stages of change and psychosocial treatment adherence among Chinese people with schizophrenia: A path analysis. Social Psychiatry and Psychiatric Epidemiology, 45, 561–568.

11.

Gerlinger

Hauser

De Hert

Lacluyse

Wampers

Correll

C. U.

(2013). Personal stigma in schizophrenia spectrum disorders: A systematic review of prevalence rates, correlates, impact and interventions. World Psychiatry, 12, 155–164.

12.

Grambal

Prasko

Kamaradova

Latalova

Holubova

Marackova

… Slepecky

(2016). Self-stigma in borderline personality disorder – Cross-sectional comparison with schizophrenia spectrum disorder, major depressive disorder, and anxiety disorders. Neuropsychiatric Disease and Treatment, 12, 2439–2448.

13.

Herdman

Gudex

Lloyd

Janssen

Kind

Parkin

… Badia

(2011). Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Quality of Life Research, 20, 1727–1736.

14.

Hill

Startup

(2013). The relationship between internalized stigma, negative symptoms and social functioning in schizophrenia: The mediating role of self-efficacy. Psychiatry Research, 206, 151–157.

15.

Holubova

Prasko

Latalova

Ociskova

Grambal

Kamaradova

… Hruby

(2016). Are self-stigma, quality of life, and clinical data interrelated in schizophrenia spectrum patients? A cross-sectional outpatient study. Patient Preference and Adherence, 10, 265–274.

16.

Holubova

Prasko

Matousek

Latalova

Marackova

Vrbova

… Zatkova

(2016). Comparison of self-stigma and quality of life in patients with depressive disorders and schizophrenia spectrum disorders – A cross-sectional study. Neuropsychiatric Disease and Treatment, 12, 3021–3030.

17.

Kondrátová

König

Mladá

Winkler

(2019). Correlates of negative attitudes towards medication in people with schizophrenia. Psychiatric Quarterly, 90, 159–169.

18.

Krajewski

Burazeri

Brand

(2013). Self-stigma, perceived discrimination and empowerment among people with a mental illness in six countries: Pan European stigma study. Psychiatry Research, 210, 1136–1146.

19.

Kvrgic

Cavelti

Beck

E. M.

Rüsch

Vauth

(2013). Therapeutic alliance in schizophrenia: The role of recovery orientation, self-stigma, and insight. Psychiatry Research, 209, 15–20.

20.

Lien

Y. J.

Kao

Y. C.

Liu

Y. P.

Chang

H. A.

Tzeng

N. S.

C. W.

… Loh

C. H.

(2015). Internalized stigma and stigma resistance among patients with mental illness in Han Chinese population. Psychiatric Quarterly, 86, 181–197.

21.

Link

B. G.

Yang

L. H.

Phelan

J. C.

Collins

P. Y.

(2004). Measuring mental illness stigma. Schizophrenia Bulletin, 30, 511–541.

22.

Livingston

J. D.

Rossiter

K. R.

Verdun-Jones

S. N.

(2011). ‘Forensic’ labelling: An empirical assessment of its effects on self-stigma for people with severe mental illness. Psychiatry Research, 188, 115–122.

23.

Wolf

Wang

(2013). Experienced stigma and self-stigma in Chinese patients with schizophrenia. General Hospital Psychiatry, 35, 83–88.

24.

Lysaker

P. H.

Davis

L. W.

Warman

D. M.

Strasburger

Beattie

(2007). Stigma, social function and symptoms in schizophrenia and schizoaffective disorder: Associations across 6 months. Psychiatry Research, 149, 89–95.

25.

Lysaker

P. H.

Roe

Ringer

Gilmore

E. M.

Yanos

P. T.

(2012). Change in self-stigma among persons with schizophrenia enrolled in rehabilitation: Associations with self-esteem and positive and emotional discomfort symptoms. Psychological Services, 9, 240–247.

26.

Mashiach-Eizenberg

Hasson-Ohayon

Yanos

P. T.

Lysaker

P. H.

Roe

(2013). Internalized stigma and quality of life among persons with severe mental illness: The mediating roles of self-esteem and hope. Psychiatry Research, 208, 15–20.

27.

Moriarty

Jolley

Callanan

M. M.

Garety

(2012). Understanding reduced activity in psychosis: The roles of stigma and illness appraisals. Social Psychiatry and Psychiatric Epidemiology, 47, 1685–1693.

28.

Mosanya

T. J.

Adelufosi

A. O.

Adebowale

O. T.

Ogunwale

Adebayo

O. K.

(2014). Self-stigma, quality of life and schizophrenia: An outpatient clinic survey in Nigeria. International Journal of Social Psychiatry, 60, 377–386.

29.

Ociskova

Prasko

Kamaradova

Grambal

Sigmundova

(2015). Individual correlates of self-stigma in patients with anxiety disorders with and without comorbidities. Neuropsychiatric Disease and Treatment, 11, 1767–1779.

30.

Park

S. G.

Bennett

M. E.

Couture

S. M.

Blanchard

J. J.

(2013). Internalized stigma in schizophrenia: Relations with dysfunctional attitudes, symptoms, and quality of life. Psychiatry Research, 205, 43–47.

31.

Ritsher

J. B.

Phelan

J. C.

(2004). Internalized stigma predicts erosion of morale among psychiatric outpatients. Psychiatry Research, 129, 257–265.

32.

Schrank

Amering

Hay

A. G.

Weber

Sibitz

(2014). Insight, positive and negative symptoms, hope, depression and self-stigma: A comprehensive model of mutual influences in schizophrenia spectrum disorders. Epidemiology and Psychiatric Sciences, 23, 271–279.

33.

Staring

A. B. P.

Van der Gaag

Van den Berge

Duivenvoorden

H. J.

Mulder

C. L.

(2009). Stigma moderates the associations of insight with depressed mood, low self-esteem, and low quality of life in patients with schizophrenia spectrum disorders. Schizophrenia Research, 115, 363–369.

34.

Świtaj

Chrostek

Grygiel

Wciórka

Anczewska

(2016). Exploring factors associated with the psychosocial impact of stigma among people with schizophrenia or affective disorders. Community Mental Health Journal, 52, 370–378.

35.

Tang

I. C.

H. C.

(2012). Quality of life and self-stigma in individuals with schizophrenia. Psychiatric Quarterly, 83, 497–507.

36.

Tsang

H. W.

(2013). Stages of change, self-stigma, and treatment compliance among Chinese adults with severe mental illness. Hong Kong Medical Journal, 19, 4–8.

37.

Tsang

H. W.

Fung

K. M.

Chung

R. C.

(2010). Self-stigma and stages of change as predictors of treatment adherence of individuals with schizophrenia. Psychiatry Research, 180, 10–15.

38.

Uhlmann

Kaehler

Harris

M. S. H.

Unser

Arolt

Lencer

(2014). Negative impact of self-stigmatization on attitude toward medication adherence in patients with psychosis. Journal of Psychiatric Practice, 20, 405–410.

39.

Valiente

Provencio

Espinosa

Duque

Everts

(2015). Insight in paranoia: The role of experiential avoidance and internalized stigma. Schizophrenia Research, 164, 214–220.

40.

Vrbová

Kamarádová

Látalová

Ocisková

Praško

Mainerová

… Ticháčková

(2014). Self-stigma and adherence to medication in patients with psychotic disorders – Cross-sectional study. Neuroendocrinology Letters, 35, 645–652.

41.

Vrbová

Kamarádová

Látalová

Praško

Cinculová

Kubínek

… Ticháčková

(2015). Sebestigmatizace, adherence k léčbě a vysazování medikace u psychotických poruch – průřezová studie [Self-stigma, adherence and discontinuation of medication in patients with psychotic disorders – cross-sectional study]. Ceska a Slovenska Psychiatrie, 111, 119–126.

42.

Vrbová

Praško

Látalová

Ocisková

Holubová

Grambal

Maráčková

(2016). Sebestigmatizace u pacientů s poruchami schizofrenního spektra [Stigmatization and self-stigmatization in patients with schizophrenia]. Ceská a Slovenská Psychiatrie, 112, 211–220.

43.

Werner

Aviv

Barak

(2008). Self-stigma, self-esteem and age in persons with schizophrenia. International Psychogeriatrics, 20, 174–187.

44.

West

M. L.

Yanos

P. T.

Smith

S. M.

Roe

Lysaker

P. H.

(2011). Prevalence of internalized stigma among persons with severe mental illness. Stigma Research and Action, 1, 3–10.

45.

Winkler

Koeser

Kondrátová

Broulíková

H. M.

Páv

Kališová

McCrone

(2018). Cost-effectiveness of care for people with psychosis in the community and psychiatric hospitals in the Czech Republic: An economic analysis. The Lancet Psychiatry, 512, 1023–1031.

46.

Yanos

P. T.

Lysaker

P. H.

Roe

(2010). Internalized stigma as a barrier to improvement in vocational functioning among people with schizophrenia-spectrum disorders. Psychiatry Research, 178, 211–213.

47.

Yanos

P. T.

Roe

Markus

Lysaker

P. H.

(2008). Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders. Psychiatric Services, 59, 1437–1442.

48.

Yanos

P. T.

West

M. L.

Gonzales

Smith

S. M.

Roe

Lysaker

P. H.

(2012). Change in internalized stigma and social functioning among persons diagnosed with severe mental illness. Psychiatry Research, 200, 1032–1034.

49.

Young

D. K.

P. Y.

(2016). The prevalence and predictors of self-stigma of individuals with mental health illness in two Chinese cities. International Journal of Social Psychiatry, 62, 176–185.