Change in Stigma Severity Following Psychiatric Hospitalisation: A Study of Associated Clinical Factors in an Indian Setting

Abstract

Background:

While stigma surrounding mental illness continues to affect management, there are hardly any studies reflecting any change following psychiatric admission. We aimed to examine how self-stigma changes during treatment in an inpatient setting and how it relates to improvements in symptoms and functioning.

Methods:

We analyzed stigma, depression, anxiety, stress, insight, well-being, functioning, and disability in 100 consecutive patients at admission and discharge in a psychiatric hospital in Kerala.

Results:

At admission, 34.5% (confidence interval [CI]: 24.5–45.7) of patients reported self-stigma, which decreased to 23.2% (CI: 15.1–32.9) at discharge; the stigma score decreased from 17.1 ± 6.6 to 14.9 ± 4.7 (p < .005). However, stigma levels did not change between admission and discharge for most (68.3%) patients; 87.5% had minimal stigma, with no scope for further reduction. In a minority (7.3%), stigma severity increased. Stigma correlated positively with depression, anxiety, functioning, and insight, and negatively with age and well-being at admission; and at discharge, positively with stress. Patients reporting stigma had higher depression, anxiety, insight, and poorer well-being both at admission and discharge.

Conclusions:

Most patients had a lower level of stigma; average stigma severity decreased during psychiatric admission; however, in a minority, it increased. While usual care was beneficial, the effectiveness of a proactive approach to stigma reduction warrants further study.

Key Messages:

• Question: Does stigma change following psychiatric hospitalization?

• Findings: Around one-third of patients experienced stigma at the time of admission, which decreased significantly by discharge.

• Meaning: Following usual psychiatric hospitalization, perceptions of stigma may change; however, specific actions towards stigma reduction in the hospital setting should be considered.

Individuals with mental disorders hold beliefs about the attitudes of the general public towards mental illness (i.e., perceived stigma), expect to be discriminated against by others because of their mental illness (i.e., anticipated stigma), and face experiences of discrimination (experienced stigma). The endorsement of negative beliefs and discriminating attitudes by the general population (i.e., public stigma) influences how stigmatized individuals perceive themselves. ¹ Self-stigma is considered present when individuals hold negative beliefs, attitudes, and behaviors stemming from the internalization of stigmatized societal ideas. ² Self-stigmatization leads to significant limitations on social participation, self-selected isolation, social disengagement, rejection of opportunities, and may pose considerable barriers to recovery. Stigma is ubiquitous and represents a significant barrier to seeking help,^3,4 accessing healthcare, and is associated with poor adherence to treatment and follow-up, increased psychiatric symptoms, adverse psychiatric outcomes, poor functional outcome, disempowerment, reduced self-efficacy, and decreased quality of life.^5–7

Higher levels of self-stigma are associated with severe mental illnesses, particularly schizophrenia, other psychotic disorders, bipolar disorder, depressive disorder, and borderline personality disorder. ⁶ Several studies from India have demonstrated that self-stigma is a concern in schizophrenia, bipolar disorder, and first-episode depression;^8–11 and it is mainly responsible for patients not receiving adequate treatment and care.^12,13 Stigma may vary in mental health care settings, such as outpatients, inpatients, and emergency care. A high level of perceived stigma towards mental illness has been reported in the general population in India.^14–17 Interestingly, a study in India reported that patients experience significantly less stigma than the general population in urban areas. ¹⁸ In contrast, patients face punitive exclusion in rural areas and active avoidance in urban areas. ¹⁹ Stigma is a strong predictor of poverty as it leads to exclusion from employment. ²⁰ The attitudes of professionals, ²¹ workplace culture, and stereotypes may perpetuate stigma and interfere with the quality of care. ³

Around one-third of people with severe mental illness report elevated self-stigma; however, research from South Asia is comparatively scant, despite a quarter of the human population living there. ⁶ Considering Indian states, the mental health burden is higher in Kerala than in other states. ²² Ambulatory and inpatient mental health care are more widely available across the state, either through general or specialist hospitals. There were no studies on self-stigma from Kerala identified in the systematic review in 2010 ²³ or in 2021. ⁶

Most studies on stigma involve community patients, mainly in remission, attending outpatient services. Self-stigma is likely to vary with the stage of illness, the care delivery setting, and the region.^6,24 Psychiatric admission, especially involuntary ones, can be stressful and stigmatizing and may affect the recovery process. ²⁵ In fact, many studies globally report that psychiatric hospitalization may increase stigma^26–28; whereas a few have reported specific interventions, such as psychoeducation delivered across different samples, that may address stigma.^29–31

There are only a few studies on stigma-reduction interventions in India, most of which involve health workers or communities. ³² Although there are studies about stigma in psychiatric inpatients and in the community in India,^8,33,34 there is hardly any research about the change of stigma following admission to a psychiatric hospital. An inpatient setting provides a real-life experience for patients and caregivers to understand symptoms, the severity of the presentation, improvement following treatment, observe presentations and changes among other patients, and assess functional improvement. There are also psychoeducational interactions with professionals to clarify doubts and misconceptions. It is prudent to explore whether hospitalization, the process of clinical improvement, recovery, and constant contact with professionals and other patients affect self-stigma.

Hypothesis

Based on the current literature, we hypothesized that, after psychiatric hospitalization, stigma would decrease among patients who showed clinical improvement.

Aims

To understand the level of self-stigma and any changes during an inpatient episode of psychiatric admission. We also studied the associated factors of stigma during the acute presentation of mental illness.

Methods

Ethical Considerations

The institutional ethics committee approved the study (approval ref. no: 003/2020; date: 6 January 2020). The Guidelines of the Declaration of Helsinki were followed in conducting the study. Patients were informed about the study, the guarantee of anonymity, and their right to withdraw consent at any time without providing a reason. Patients who agreed to participate provided written informed consent. No identifiable details were collected during the data collection.

Study Design

This was a prospective observational study using routinely collected clinical data from patients admitted to an indep-endent, acute mental health care provider in central Kerala.

Setting

This 48-bed center offers mental health care for a wide range of mental disorders across the lifespan. As part of the admission assessment, patients were evaluated by trained mental health professionals (assistant psychologists) using a structured interview schedule that included standardized scales.

Inpatient Interventions

The usual care of psychiatric inpatients included medicinal treatment for mental illnesses. In addition, patients received psychoeducation, psychological interventions appropriate for acute care settings, occupational therapy, and group interventions. Psychoeducation was also provided to caregivers. However, these were non-specific to stigma.

Participants

Consecutive patient records of 100 adult psychiatric admissions between October and December 2020 were selected for data extraction. Coronavirus disease (COVID-19) pandemic-related restrictions ended in June 2020. All inpatients were included irrespective of diagnosis or illness duration, and no exclusions were made. Clinical diagnoses were made based on the International Classification of Diseases, 10th Revision criteria. ³⁵

Variables

We assessed stigma, along with subjective experiences of depression, anxiety, stress, work and social adjustment, well-being, and insight to study the clinical correlates of stigma.

Tools

Stigma was measured using the 9-item Internalized Stigma of Mental Illness Inventory, a self-report measure. ³⁶ It measures five themes of internalized stigma of mental illness: Alienation, stereotype endorsement, perceived discrimination, social withdrawal, and stigma resistance. Higher scores on this scale indicate higher self-stigma. The scores are interpreted in a 4-category method: 1.00–2.00: Minimal to no internalized stigma, 2.01–2.50: Mild internalized stigma, 2.51–3.00: Moderate internalized stigma, and 3.01–4.00: Severe internalized stigma. ³⁷ This was translated and validated in Malayalam, the local language. ³⁸

We used the Beck Depression Inventory (BDI) to assess the degree of depression. The total BDI score (range 0–63) is categorized as follows: 0–13 minimal, 14–19 mild, 20–28 moderate, and >29 severe depression. ³⁹ Anxiety was assessed using the Beck Anxiety Inventory (BAI). The total BAI score (range 0–63) is categorized as: 0–7 minimal, 8–15 mild, 16–25 moderate, 26–63 severe. ⁴⁰ Anxiety and depression were assessed as part of a holistic assessment of all illnesses, as these are common symptoms in many disorders.

The Perceived Stress Scale (PSS) was used to measure stress. ⁴¹ Total PSS scores (range 0–40) are categorized as 0–13 (low stress), 14–26 (moderate), and 27–40 (high stress). ⁴¹

Insight was assessed through the InMind Insight Scale (IIS). ⁴² It is a 10-item questionnaire with a score range of 0–30; higher scores indicate greater insight. Cronbach’s alpha for IIS was 0.845, indicating high internal consistency in the sample.

The Short Warwick–Edinburgh Mental Well-being Scale was used to study well-being. Scores range from 7 to 35, with higher scores indicating greater positive mental well-being. ⁴³

We used the Work and Social Adjustment Scale (WSAS) to measure the current level of functioning. ⁴⁴ On a 0 (not at all) to 8 (very severely) scale measuring impairment, it assesses five areas: Ability to work, home management, social leisure activities, private leisure activities, and maintaining close relationships. A WSAS score was categorized as severe (above 20), less severe (between 10 and 20), and subclinical (below 10). ⁴⁴ It is sensitive to change following intervention in different treatment settings and across diagnoses.^44,45

The World Health Organization Disability Assessment Schedule (WHODAS-2) was used to assess disability of the patients. It is a 12-item scale with a score range of 0–48, where a high score suggests high disability. Persons scoring 10–48 are likely to have a clinically significant disability. ⁴⁶

Data Collection

The self-rated scales were used routinely during the admission period. These were introduced to patients and explained by clinical staff, including nurses and doctors. The patients were given privacy to complete the form; however, if they needed any help with the explanation, they were supported by a clinician. Assessments after admission were conducted when individuals were able to participate in the process and reflect on their well-being. Assessments at discharge were conducted once hospital discharge plans were finalized. All staff involved in the study shared the same ethnic background as the patients. Data for this study were collected from clinical case records of consenting patients and entered into a Microsoft Excel database. The data were checked for completeness and accuracy.

Statistical Analysis

Analysis was carried out using the IBM SPSS Statistics (version 28, Armonk, NY). We used 95% confidence intervals (CIs) for proportions, chi-square tests, t-tests, paired t-tests, Pearson’s correlation, Cohen’s d for effect size, and linear regression. Statistical significance was considered for p values < .05. Missing values were excluded from the analysis.

Results

Participant Characteristics

The sample comprised 100 consecutive inpatients, all of Indian background. The sample was primarily male (65%), married (61%), unemployed (56%), and 83% were educated at a high school level or above. The mean age of male patients (39.2 ± 13.9 years) was comparable to that of female patients (40.8 ± 18.5). In all the studied parameters, the genders were comparable, except for the disability based on WHO DAS-2 score at admission (male: 6.95 ± 7.3 vs. female: 11.3 ± 11.2) and at discharge (3.3 ± 4.1 vs. 6.4 ± 9.9 respectively) (p < .05). Diagnostic breakdown showed that 29% had psychotic disorders, 13% bipolar disorder, 8% depression, 10% personality disorder, 20% alcohol dependence and 20% other diagnoses (Table 1).

Table 1.

Diagnostic Breakdown Among Genders.

Primary Diagnoses	Male n (%)	Female n (%)	Total n (%)	95% CI
1. Psychotic disorders	21 (32.3)	8 (22.9)	29 (29.0)	21.0–38.5
2. Depression	3 (4.6)	5 (14.3)	8 (8.0)	4.1–15.0
3. Bipolar disorder	9 (13.8)	4 (11.4)	13 (13.0)	7.8–21.0
4. Personality disorder	0 (0.0)	10 (28.6)	10 (10.0)	5.5–17.4
5. Alcohol dependence	20 (30.8)	0 (0.0)	20 (20.0)	13.3–28.9
6. Other diagnoses	12 (18.5)	8 (22.9)	20 (20.0)	13.3–28.9

CI: Confidence interval of total proportion.

Self-reported mental health and well-being measures, along with stigma levels, are presented in Table 2. The duration of hospitalization for the whole sample ranged from 6 to 116 days (mean 22.6 ± 14.7), with no significant difference between male (22.1 ± 10.9) and female (23.7 ± 20.4) patients. Individual-level data analysis (using paired sample t-test) showed that measures of depression, anxiety, stress, work and social adjustment, disability, and insight changed significantly at discharge (Table 3).

Table 2.

Difference in Stigma and Clinical Categories Between Genders.

Variables	Categories	Admission			Discharge
		Male n (%)	Female n (%)	Total n (%)	Male n (%)	Female n (%)	Total n (%)
Stigma	Minimal	35 (67.3)	20 (62.5)	55 (65.5)	48 (77.4)	25 (75.8)	73 (76.8)
	Mild	6 (11.5)	7 (21.9)	13 (15.5)	8 (12.9)	4 (12.1)	12 (12.6)
	Moderate	7 (13.5)	3 (9.4)	10 (11.9)	6 (9.7)	3 (9.1)	9 (9.5)
	Severe	4 (7.7)	2 (6.3)	6 (7.1)	0 (0.0)	1 (3.0)	1 (1.1)
Stress	Low	18 (28.6)	7 (20.0)	25 (25.5)	34 (53.1)	18 (52.9)	52 (53.1)
	Moderate	25 (39.7)	10 (28.6)	35 (35.7)	22 (34.4)	14 (41.2)	36 (36.7)
	High	20 (31.7)	18 (51.4)	38 (38.8)	8 (12.5)	2 (5.9)	10 (10.2)
Depression	Minimal	21 (33.3)	10 (28.6)	31 (31.6)	46 (71.9)	23 (67.6)	69 (70.4)
	Mild	8 (12.7)	2 (5.7)	10 (10.2)	6 (9.4)	8 (23.5)	14 (14.3)
	Moderate	15 (23.8)	5 (14.3)	20 (20.4)	5 (7.8)	1 (2.9)	6 (6.1)
	High	19 (30.2)	18 (51.4)	37 (37.8)	7 (10.9)	2 (5.9)	9 (9.2)
Anxiety	Minimal	34 (54.0)	13 (37.1)	47 (48.0)	49 (76.6)	27 (79.4)	76 (77.6)
	Mild	11 (17.5)	11 (31.4)	22 (22.4)	7 (10.9)	6 (17.6)	13 (13.3)
	Moderate	7 (11.1)	5 (14.3)	12 (12.2)	4 (6.3)	1 (2.9)	5 (5.1)
	Severe	11 (17.5)	6 (17.1)	17 (17.3)	4 (6.3)	0 (0.0)	4 (4.1)
Disability	Low	47 (72.3)	19 (54.3)	66 (66.0)	59 (90.8)	27 (77.1)	86 (86.0)
	High	18 (27.7)	16 (45.7)	34 (34.0)	6 (9.2)	8 (22.9)	14 (14.0)
WSAS	Subclinical	21 (33.3)	9 (25.7)	30 (30.6)	33 (52.4)	19 (55.9)	52 (53.6)
	Moderate	16 (25.4)	7 (20.0)	23 (23.5)	15 (23.8)	8 (23.5)	23 (23.7)
	Severe	26 (41.3)	19 (54.3)	45 (45.9)	15 (23.8)	7 (20.6)	22 (22.7)

Non-significant; WSAS: Work and social adjustment scale.

Table 3.

Comparison of the Change of Stigma and Clinical Characteristics at Admission and Discharge.

	Admission	Discharge	Statistic*	Effect Size
	Mean ± SD	Mean ± SD	t, df, p	(d)
Stigma	17.1 ± 6.6	14.9 ± 4.7	3.1, 81, <.005	0.347
Stress	21.7 ± 10.4	12.8 ± 9.9	7.3, 95, <.001	0.749
Depression	24.2 ± 15.7	10.2 ± 10.9	9.2, 95, <.001	0.93
Anxiety	12.3 ± 12.9	4.6 ± 7.1	6.3, 95, <.001	0.643
Insight	15.5 ± 8.4	16.9 ± 9.2	−2.2, 95, <.05	−0.223
Disability	8.5 ± 9.0	4.4 ± 6.8	8.4, 99, <.001	0.840
WSAS	18.3 ± 13.3	11.6 ± 11.8	6.3, 94, <.001	0.646
Wellbeing	23.2 ± 7.8	29.1 ± 6.0	−7.5, 95, <.001	−0.769

*Paired t-test. Effect size (d): Cohen’s d.

Levels of Stigma

Among the 100 consecutive patients, information on stigma was available for 84 at admission and 95 at discharge; in 82, it was available for both periods. The data were unavailable because patients did not complete the questionnaire. The mean stigma at admission was 16.99 ± 6.5 (n = 84) and at discharge 15.2 ± 4.9 (n = 95). At admission, most (65.5%, 95% CI: 54.3–75.5) patients had minimal level stigma (Table 2), suggesting 34.5% (CI: 24.5–45.7) had some level of stigma; mild in 15.5% (CI: 8.5–25.0) and moderate/severe in 19.1% (CI: 11.3–29.1). At discharge, the majority had minimal (76.8%, 95% CI: 67.1–84.9), that is, 23.2% (CI: 15.1–32.9) had some level of stigma, mild in 12.6% (CI: 6.7–21.0), and moderate/severe in 10.5% (CI: 5.2–18.5).

The stigma significantly decreased between admission and discharge (Table 3). The mean change of stigma score was 2.1 ± 6.1 with a range from −17.0 to 22.0, suggesting that in some patients, stigma increased. With the available stigma scores for 82 patients both at admission and discharge, the stigma categories of 56 (68.3%) people did not change (Table 4). For the remaining 26 (31.7%), there was a change; 6 (7.3%) people had their stigma severity increased, and 20 (24.4%) had the stigma severity decreased. Between admission and discharge, excluding the unchanged proportion, the change in different levels of stigma was as follows: Minimal changed from 4 to 17, mild from 8 to 3, moderate from 8 to 5, and severe from 6 to 1, indicating that levels of stigma decreased in all categories from mild to severe, with the most apparent being in the severe group.

Table 4.

Change in Categories of Stigma.

Admission (n)→	Minimal (53)	Mild (13)	Moderate (10)	Severe (6)	Total (82)
Discharge ↓	n (%)	n (%)	n (%)	n (%)	n (%)
Minimal	49 (92.5)	6 (46.2)	7 (70.0)	4 (66.7)	66 (80.5)
Mild	2 (3.8)	5 (38.5)	1 (10.0)	0 (0.0)	8 (9.8)
Moderate	1 (1.9)	2 (15.4)	2 (20.0)	2 (33.3)	7 (8.5)
Severe	1 (1.9)	0 (0.0)	0 (0.0)	0 (0.0)	1 (1.2)

Patients (n = 82) who had both admission and discharge information on stigma.

Correlates of Stigma

Stigma correlated with many variables studied at admission (Table 5). Depression, anxiety, impairment in work (WSAS score), and insight had a positive correlation, whereas age and well-being had a negative correlation with stigma. At discharge, stigma had a similar correlation as admission, except that there was no significant correlation with age, and had a significant positive correlation with stress. The number of hospital days did not correlate with stigma. Linear regression analysis of the study variables did not identify any specific factor that significantly contributed to stigma at either admission or discharge.

Table 5.

Correlation of Different Variables with Stigma at the Time of Admission.

	Adm Days	Depression	Anxiety	Stress	WSAS	Wellbeing	Disability	Stigma	Insight	Age
Adm days	– (100)
Depression	−.012 (98)	–
Anxiety	−.013 (98)	.548** (98)	–
Stress	.031 (98)	.554** (98)	.393** (98)	–
WSAS	.124 (98)	.477** (98)	.211* (98)	.517** (98)	–
Wellbeing	.152 (98)	−.640** (98)	−.300** (98)	−.511** (98)	−.488** (98)	–
Disability	.056 (100)	.114 (98)	.173 (98)	.018 (98)	.152 (98)	−.211* (98)	–
Stigma	−.018 (84)	.369** (84)	.291** (84)	.205 (84)	.244* (84)	−.395** (84)	.170 (84)	–
Insight	−.023 (98)	.587** (98)	.409** (98)	.384** (98)	.454** (98)	−.362** (98)	.029 (98)	.217* (84)	–
Age	.064 (100)	−.103 (98)	−.039 (98)	−.070 (98)	−.155 (98)	.172 (98)	.211* (100)	−.219* (84)	−.031 (98)	–

*p <.05, **p < .01.

Adm days: Number of hospital admission days, WSAS: Work and social adjustment scale.

Figures in parentheses are N.

We compared patients who reported minimal stigma with those who reported mild, moderate, or severe stigma (Table 6). People with higher stigma at admission had significantly higher depression, anxiety, disability, and work and function impairments, poorer well-being, and better insight. At the time of discharge, the higher stigma group had higher reported stress, depression, anxiety, poorer well-being, and better insight. Admission days of patients with minimal stigma (23.7 ± 16.8) were not statistically different from those who reported a degree of trauma (20.0 ± 9.9).

Table 6.

Comparison of Minimal Stigma with Mild, Moderate, or Severe Stigma, at Admission and Discharge.

	Admission				Discharge
	Minimal Stigma	Stigma	t, df, p	D	Minimal Stigma	Stigma	t, df, p	d
Stigma	13.2 ± 3.3	24.2 ± 4.7	−12.5, 82, <.001	−2.869	13.0 ± 3.0	22.3 ± 3.2	−12.6, 93, <.001	−3.060
Stress	20.3 ± 10.6	24.6 ± 9.2	−1.8, 82, .068	−.424	12.03 ± 9.6	17.0 ± 10.5	−2.1, 93, .040	−.506
Depression	19.7 ± 15.2	31.6 ± 13.2	−3.6, 82, <.001	−.818	9.0 ± 9.8	16.6 ± 14.5	−2.9, 93, .005	−.694
Anxiety	9.9 ± 12.8	16.5 ± 13.2	−2.2, 82, .029	−.511	3.6 ± 6.1	9.5 ± 10.0	−3.3, 93, .001	−.808
Insight	14.5 ± 8.4	18.4 ± 7.7	−2.1, 82, .042	−.475	16.5 ± 9.0	21.1 ± 9.1	−2.1, 93, .041	−.504
Disability	6.9 ± 8.1	11.1 ± 8.8	−2.2, 82, .033	−.498	3.8 ± 6.2	5.1 ± 4.5	−.9, 93, .36	−.224
WSAS	16.8 ± 12.8	22.7 ± 11.7	−2.1, 82, .041	−.476	11.0 ± 11.7	15.1 ± 12.0	−1.4, 92, .155	−.350
Wellbeing	25.6 ± 7.2	20.0 ± 7.3	3.3, 82, .001	.761	30.1 ± 5.6	25.6 ± 6.8	3.2, 93, .002	.776

WSAS: Work and social adjustment scale, d: Effect size Cohen’s d.

Stigma did not differ across sociodemographic variables, except that more unemployed patients had higher stigma at discharge (34% vs. 9.5%; chi-square test, p < .05). There were no differences in stigma or other study variables between patients with psychosis and non-psychotic disorders, except for insight at admission (12.5 ± 8.8 vs. 16.5 ± 8.2, p < .05), which was comparable at dis-charge (15.9 ± 10.1 vs. 17.7 ± 9.0, respectively). There was no difference in stigma when severe illnesses such as psychosis and bipolar disorder were compared against other disorders.

Discussion

This study shows that nearly a third of patients admitted to a psychiatric hospital in Kerala, Southern India, experienced a certain degree of self-stigma, which decreased to around a quarter at the time of discharge. This proportion of patients reporting stigma is toward the lower end of the global range (22.5%–97.4%) reported in various settings. ⁴⁷ Higher frequency of stigma has been reported from South-East Asia and the Middle East. ⁶ A nationwide study from India, among patients with severe mental disorders (schizophrenia, bipolar disorder, and recurrent depressive disorder) in remission, found 37.9% of patients had self-stigma. ⁸ Stigma has also been reported in a higher proportion of patients with common mental disorders attending outpatient psychiatry clinics. ⁴⁸ Similarly, higher levels of self-stigma have been reported by 41.1% of first-episode depression, ¹¹ 29% of those with schizophrenia in remission, ⁴⁹ and 28% of bipolar disorder in remission had moderate to high levels of stigma. ⁵⁰

Kerala is known for higher literacy rates, health indicators, and other human development indices than other Indian states. A lower degree of public stigma towards mental illness is likely in this population, and this might contribute to a parallel reduction in self-stigma. Moral or supernatural causal attributions of mental illness, ⁵¹ a factor considered to be contributing to higher stigma in certain cultures, including India, ⁵² are possibly less firmly held in Kerala. Better accessibility to mental health services and higher acceptance of help-seeking might also have contributed to the lesser degree of self-stigma observed in this sample.

A few existing studies on self-stigma in India have been conducted among patients in remission living in the community. A study from Kerala previously reported that 34.1% of hospital patients in tertiary-care public hospitals reported high self-stigma, compared with 44.7% among community counterparts. ³⁴ The hospital’s cultural and social milieu, along with frequent contact with other patients, may affect self-stigma experiences.

Factors Associated with Stigma

In our study, age was negatively correlated with stigma; higher age was associated with lower stigma. Similar observations have been reported by another study from India, where a younger age of onset and an early phase of illness were associated with higher stigma. ⁸ A study from Kerala reported that self-stigma was more severe among the under-45 age group. ³³ It appears that younger people are more vulnerable to self-stigma and thus require targeted interventions. Our study did not examine the duration of illness, the duration of treatment, or the age of illness onset.

In global literature, the association between socio-demographic factors and self-stigma is generally inconsistent. ⁶ We found no sociodemographic variables associated with self-stigma, except that age was negatively associated with stigma. A study in India reported that schizophrenia patients with employment had higher scores on stigma resistance. ⁴⁹

We compared patients with psychotic and nonpsychotic disorders and did not find any difference in stigma level. It has been reported that individuals with schizophrenia experience more self-stigma compared with those with other severe mental disorders. ⁶ Similar findings have been reported from India as well. ⁸ In contrast, in our study, self-stigma was not higher in psychotic illnesses.

Patients with a higher level of stigma at admission in this study had higher depression, anxiety, disability, and work and functional impairments, poorer well-being, and better insight. A positive relationship of self-stigma with insight and depression has been reported, as well as a negative relationship with well-being. ⁶ There are observations that people who recognize the need for psychiatric consultation and intervention have higher stigma. ⁵³ At the time of discharge, patients with higher stigma had higher stress, depression, anxiety, poorer well-being, and better insight. It appears that these relationships are persistent and may not change following a single episode of psychiatric admission. This likely suggests targeted approaches are needed to address stigma, ⁵⁴ rather than relying on routine care.

Change in Stigma

This study shows that self-stigma can decrease during a relatively short period of time during psychiatric admission, which was on average around three weeks in this study. Although longitudinal studies comparing inpatient hospitalizations are scarce, a few hospital-based studies have evaluated stigma. A study in Japan found no change in self-stigma at one month post-admission, at discharge, or at the first community follow-up. ⁵⁵ A study on children in London treated as inpatients or outpatients found no difference in stigma except for personal rejection at baseline and self-stigma at follow-up, favoring outpatients. ⁵⁶ A study in Germany on psychotherapy inpatients reported that both self-stigma and perceived public stigma decreased during the course of the psychotherapy, with the decrease in self-stigma being significant, which highlighted that self-stigma might change during the course of an inpatient psychotherapeutic treatment. ⁵⁷ A multimedia-based anti-stigma campaign in India reported improvements in knowledge, attitudes, and behaviors over two years post-campaign. ⁵⁸

A significant degree of reduction in depression, anxiety, stress, and improvements in functional status, well-being, work, and social adjustment, and insight seen during the admission period would have contributed to the reduction in self-stigma. While a routine psychiatric admission can reduce stigma severity, a proactive approach to stigma reduction may further reduce it. There is a need to develop specific approaches at multiple levels to reduce stigma.^32,59

The majority of patients (64.6%) had minimal stigma (level one) at admission. For a large proportion (87.5%, 49/56) of patients, the stigma level did not change during the admission, as they were already at the minimal level of stigma. This “ground floor” effect (i.e., no further reduction is possible beyond the minimal-stigma category) might explain the observation that stigma categories did not change for the majority of patients. The 7.3% increase in stigma was intriguing and was not correlated with insight or diagnosis. Admission to a psychiatric hospital is a known contributor to stigma in itself.^26–28 Given the small number of participants in our study who had an increase in stigma, further studies with larger samples are required to understand this phenomenon.

Strengths and Limitations

To our knowledge, this is the first study from India to compare the change in stigma following psychiatric admission. We consider this study unique because patients were assessed at two critical points during their acute illness while hospitalized. This provides an opportunity to examine whether self-stigma changes in response to changes in symptoms and recovery-related outcome measures. The repeated measures taken at discharge allow exploration of factors that may help reduce self-stigma.

There are several limitations to this study. The sample was drawn from a single hospital, a private hospital in which patients pay for their treatment. This suggested that the sample may belong to higher socioeconomic strata than patients receiving free treatment at the government hospitals. For these reasons, the results cannot be considered generalizable to all acutely unwell psychiatric patients or settings. The study findings cannot specify the cause of the change in stigma levels, which may be due to various factors, such as clinical input at the hospital, and different inpatient setups may differ in this regard. A sample size calculation was not conducted before the study. The sample size is small; therefore, some associations could not be tested for significance. We did not examine comorbidity, illness duration, or admission type (voluntary or involuntary), all of which are essential contributors to stigma. The scale used to assess insight is not standardized; however, internal consistency is good in this patient sample. This study could not reflect any persistence of the change in stigma beyond the discharge. In addition, there is a possibility of responder bias.

Conclusions

Self-stigma was experienced by around a third of patients with acute mental health conditions requiring hospital care in Kerala. Sociodemographic factors and diagnostic categories in general did not show an association with self-stigma. By the time the inpatient episode was finished, stigma levels showed a substantial reduction. Reduction in self-stigma was associated with improvements in symptoms and recovery-related outcomes. Admission to a psychiatric hospital is likely to evoke strong stigma responses in an individual, and this makes assessing stigma extremely important in the personal recovery process. Inpatient settings can provide an invaluable opportunity to address self-stigma. Further studies are needed to explore the link between public stigma and self-stigma and to find out the effectiveness of structured stigma resistance interventions.