Introduction
The World Health Organization has defined stigma as a mark of shame, disgrace, or disapproval that results in an individual being rejected, discriminated against, and excluded from participating in a number of different areas of society.1 At the individual level, self-stigma can be described as a process whereby affected individuals are exposed to stereotypes, anticipate social rejection, consider stereotypes to be self-relevant, and believe they are devalued members of society. 2 Internalized stigma is experienced when a person accepts and believes in the stereotype that describes the stigmatized group and then finally applies it to themselves. Self-esteem is an individual's subjective evaluation of their own worth. It consists of beliefs about one-self. 3 The self-esteem, is the positive or negative evaluations of the self, as in how we feel about oneself. 4 Very little data is known about the extent of internalized stigma and self -esteem experienced by treatment seeking patients with psychiatric disorders. In India, the prevalence of depression is about 15%5 and that of anxiety is around 20%.6 Out of these, only certain number of people choose to consult a doctor for their symptoms. The way the psychiatric disorders are addressed by not only the society but also by the patients themselves affects their course of treatment, compliance to medications, their interpersonal relations with the surrounding people, their confidence and self -esteem. This study aims to study the proportion of self-stigma and self- esteem in patients with anxiety and depression. In turn giving us an idea on how psychiatric disorders are perceived in the society. Along with this, the factors which affect self-stigma and self-esteem would be assessed.
Materials and Methods
The study design is an observational cross sectional study which is conducted in a psychiatry outpatient department of a tertiary care hospital in a total duration of 3 months.50 consecutive patients diagnosed depression and anxiety using DSM-5 were included in the study between age group of 18-60 years. This study included participants who were willing to give written informed consent. Participants who were already diagnosed with some other major psychiatric or medical condition were excluded from the study. Permission from the Institutional Ethics Committee was taken and participants fulfilling the inclusion and exclusion criteria were included in the study. A semi-structured proforma was used to collect socio-demographic details and clinical data. Internalized Stigma of Mental Illness (ISMI) and Rosenberg's Self Esteem Scale (RSES) were used to assess self-stigma and self-esteem in patients diagnosed with anxiety and depression using DSM-5.
Rosenberg's Self Esteem Scale (RSES) is a 10 item scale, where respondents indicate how strongly they agree or disagree with the statements, using a Likert scale from strongly agree (1) through to strongly disagree (4).7 Scores of items 2, 5, 6, 8, 9 are reversed.
All item scores are then summed and higher scores indicate higher self‐ esteem whereas lower scores indicate low self-esteem.
The score of the scale is from 0-30. Below 15 indicates low self- esteem and 15‐25 are within normal range. Above 25 score indicates high self-esteem.
The Internalized Stigma of Mental Illness (ISMI) scale was used to measure internalized stigma. The scale has 4‐point likert scale from strongly disagree to strongly agree to rate each of the 9 items. 8
For the interpretation of scores, 4 category method was used. The grading is as follows
1-2-minimal to no internalized stigma
Results & Discussion
Table 1
Sociodemographic details and results found on clinical profile
Data collected from semi-structured proforma showed that the mean age of participants was 38.88 years with 64% females, majority being married. It was seen that majority of the participants lived in the urban area. Most have them had education till tenth standard. Most of the participants were either working or were housewives. The duration of illness of maximum participants was between 1 to 5 years. Around 84% participants were on treatment. There was history of deliberate self -harm attempt in 12%. There was history of faith healing in 20% participants. The interpersonal relations were cordial in 52% and history of stressors were present in about 76% participants at the onset of the illness.Table 1
Among the participants, 31 were diagnosed with depression and 19 were diagnosed with anxiety.
Self-stigma
The Internalized Stigma of Mental Illness (ISMI) scale was used to assess self-stigma.
High self-stigma was found in 28 participants that is 56%. High self-stigma included moderate and severe level of stigma which consisted of 7 and 21 participants respectively.
No to mild level was included in low self-stigma group. Out of which, 18 were females and 10 were males. About 57.90% resided in urban area and 68.29% participants were literate and educated compared to 33.33% who weren’t.
Table 2
Self-stigma
|
|
Self Stigma |
|
|
|
|
Diagnosis |
Low |
High |
Chi square df=1 |
P |
|
Anxiety (%) |
8(42.1) |
11(57.9) |
0.022 |
1 |
|
Depression (%) |
14(45.2) |
17(54.8) |
|
|
On using Chi-square test to analyze the data, it was seen that self-stigma was more in anxiety disorder compared to depression.Table 2
Self –esteem
Rosenberg's Self Esteem Scale (RSES) was used to assess self-esteem. Out of 50 participants, 27 (54%) participants had low self-esteem. Out of 27 participants 18 were females and 9 were males. Low self-esteem was seen more in literate and educated participants that is in 56.10%.
Table 3
Self esteem
|
|
Self esteem |
|
|
|
|
Diagnosis |
Low |
Normal |
Chi square df=1 |
P |
|
Anxiety |
8(42.1) |
11(57.9) |
1.059 |
0.304 |
|
Depression |
19(61.3) |
12(38.7) |
|
|
Low self-esteem was found more in depression (61.90%) as compared to anxiety disorders.Table 3
Association between self-stigma and self-esteem
Table 4
Self-stigma and self-esteem
|
|
Low Self-stigma |
High Self-stigma |
|
Low self- Esteem |
22.2 |
77.8 |
|
High self-Esteem |
69.6 |
30.4 |
It was seen that low self- esteem was associated with high self-stigma and high self-esteem was associated with low.Table 4
Self-stigma
According to a study done in 2018, AbdAl-HadiHasan et al studied self-stigma in patients diagnosed with schizophrenia, depression and anxiety. It was seen that self-stigma was seen more in patients with schizophrenia whereas that in anxiety and depression were seen almost identically.9
According to Picco L et al in 2016 who studied Internalized stigma among psychiatric outpatients and associations with quality of life, functioning, hope and self-esteem, found that 43.6% experienced moderate to high internalized stigma. There were no significant socio-demographic or clinical correlates relating to internalized stigma which was also seen in this study. A negative relationship between quality of life, self-esteem and general functioning and internalized stigma was observed whereby lower scores were associated with higher internalized stigma10 which was also seen in this study.
In 2016, Pasmatzi E et al studied Self-stigma, self-esteem and self-efficacy of psychiatric patients. Greater self-stigma was associated with lower self-esteem and educational level were the most significant predictors of both self-esteem and self-efficacy in psychiatric patients. This study also mentioned that the percentage of low self-esteem (30.3%), were different from previous relevant data (9.1–24%), probably due to differences in sample’s cultural characteristics and the degree of reaction to social stigma. 11
In 2015, in a study done by Zuzana Sedláčková et al, treatment adherence and self-stigma in patients with depressive disorder was studied. Around 53% participants had high self -stigma. The study results suggest that the rate of self-stigma may be a significant factor which could be associated with poorer adherence of patients with major depressive disorder hence a great perspective for increasing adherence may be strategies for reduction of self-stigma, which can be implemented by psychoeducation of patients and the relatives.12
According to a study done in 2014, relationship between internalized stigma and treatment efficacy in mixed neurotic spectrum and depressive disorders was studied by Marie Ociskova et al, Czech Republic. It was seen that the consequence of these internalized prejudices is decreased treatment efficacy. Moderately to high internalized stigma was seen in depression and anxiety. It was also found that patients who highly stigmatize themselves, improved less during treatment than patients with lower levels of self-stigma.13, 14, 15
Conclusion
It was observed that both high self-stigma (56%) and low self-esteem (54%) was significantly high in the participants.
There wasn’t any significant difference in percentages of high self-stigma and low self-esteem when compared between anxiety disorders and in depression. There were no significant socio-demographic or clinical correlates relating to self- stigma and self-esteem according to this study.
It was seen that low self- esteem was associated with high self-stigma and high self-esteem was associated with low self-stigma.
A systematic measurement of self-stigma and self-esteem provides clinicians with a target for general psychotherapeutic interventions which would to dispel misconceptions relating to psychiatric disorders thus increasing the chances of compliance to treatment and medications. This would lead to better prognosis. Thus, assessing self-stigma and self-esteem should be made an important part of the treatment for overall betterment of the patient.
