Abstract
Background
Major depressive disorder (MDD) in adolescents is increasingly prevalent and associated with high recurrence, suicide risk, and disease burden. Family caregivers, typically parents or close relatives, often internalize public stigma, resulting in affiliate stigma—shame and distress arising from their association with patients. This stigma impairs caregivers’ mental health, quality of life, and patients’ recovery. However, few studies have explored how psychosocial factors such as social support, coping style, and family functioning influence affiliate stigma. This study therefore examines its score level, influencing factors, and the mediating roles of family functioning and coping style.
Methods
A cross-sectional study we conducted at a mental health center in Inner Mongolia, China. A total of 308 family caregivers of adolescents diagnosed with MDD were recruited. Demographic information, affiliate stigma, social support, family functioning, and coping styles were assessed using validated instruments. Data we analyzed using IBM SPSS Statistics 26.0 and AMOS 24.0 to examine the influencing factors of affiliate stigma and the underlying mechanisms through structural equation modeling.
Results
The average affiliate stigma score among caregivers was74.922 ± 9.834. Multiple regression analysis showed that social support, family functioning, positive and negative coping styles, gender, education level, household income, and whether the adolescent was experiencing a first depressive episode independently predicted of affiliate stigma (P < 0.05), explaining 65.5% of the variance (R² = 0.655). The structural equation model showed acceptable fit with room for improvement (χ² = 2431.24, df = 1394,; χ²/df = 1.744; RMSEA = 0.075; CFI = 0.905; GFI = 0.914;IFI = 0.916;TLI = 0.913). Social support had indirect effects on affiliate stigma via family functioning (-6.5%) and coping styles (-9.5%), with all pathways being statistically significant (P < 0.01).
Conclusions
Family caregivers of adolescents with MDD experience moderately high levels of affiliate stigma. Social support not only directly influences stigma but also exerts indirect effects through family functioning and coping strategies. Interventions should focus on improving family functioning and promoting adaptive coping to reduce affiliate stigma.
Keywords: Depression, Family caregivers, Affiliate stigma, Family functioning, Coping style
Introduction
Major depressive disorder is one of the most common psychiatric disorders among adolescents and is characterized by persistent and significant depressed mood [1]. In recent years, the onset of MDD has occurred at increasingly younger ages, with individuals aged 12 to 18 being at particularly high risk [2]. Adolescent MDD is associated with a high prevalence, a high recurrence rate, an elevated risk of suicide, a significant disease burden, and low recovery rates, making it a critical concern for global public health [3, 4].
Family caregivers—typically unpaid individuals such as parents, siblings, spouses, or other relatives—bear the primary responsibility of supporting and caring for patients [5]. Due to their close association with individuals who are mentally ill, caregivers often internalize public stigma and become susceptible to psychological distress, including shame and social withdrawal [6–8]. This phenomenon is known as affiliate stigma, which refers to the internalized stigma experienced by individuals associated with someone who is stigmatized, despite not being mentally ill themselves [9–12].
Affiliate stigma can adversely impact caregivers’ mental health, quality of life, and social functioning, and it may also negatively affect patients’ recovery, recurrence, and reintegration into society. Some caregivers may develop pessimistic attitudes about the illness or prognosis and, in extreme cases, become what scholars describe as “hidden patients” themselves due to overwhelming caregiving stress [13, 14].
Previous studies on affiliate stigma among caregivers of adolescents with MDD have mainly focused on patient-related factors, while few have explored the effects of social support, coping styles, or family functioning, and the pathways through which these psychosocial variables influence stigma remain underexplored. From the perspective of transactional stress–coping theory, social support is a key external resource that shapes how individuals appraise and respond to stressors; it influences the selection of coping strategies and, through these processes, subsequent psychological outcomes [15]. By providing emotional, informational, and instrumental resources, social support can alleviate caregivers’ anxiety and depressive symptoms and foster more constructive responses to clinical care and nursing interventions [16]. Classic work on social support and the buffering hypothesis further suggests that supportive relationships can attenuate the negative impact of stress on mental health by promoting more adaptive emotion- and problem-focused coping [17]. Consistent with the McMaster Model of Family Functioning, greater support may strengthen family processes, reduce conflict, and improve role performance, which in turn buffers stigma-related distress [18]. Well-functioning families can mobilize material resources and psychological support from within the family, thereby enhancing caregivers’ capacity for emotional self-regulation, strengthening their sense of self-efficacy, and reducing the likelihood of anxiety and depression [19]. Empirical research in child and family studies has shown that higher levels of parental social support are associated with better family well-being and parenting quality, which in turn foster more adaptive coping and resilience in families facing chronic child mental health problems [20]. Conversely, caregivers who rely predominantly on maladaptive coping strategies are more prone to persistent negative emotions, which may worsen the perceived severity of the illness and amplify internalized stigma; in contrast, those who adopt more active and problem-focused coping are better able to seek and utilise social support, address experiences of discrimination or devaluation, relieve psychological stress, and ultimately maintain lower levels of affiliate stigma [21]. These theoretical and empirical insights together imply that social support may be linked to affiliate stigma not only directly, but also indirectly via its influence on family functioning and caregivers’ coping styles.
Integrating these perspectives, we propose a coherent pathway in which social support affects both family-level processes and individual coping patterns, jointly influencing the development and maintenance of affiliate stigma among family caregivers. Therefore, this study aims to investigate the current state of affiliate stigma and its influencing factors, and to construct a model to examine the mediating roles of family functioning and coping styles.
Methods
Study design and participants
This cross-sectional study was conducted between September 2023 and October 2024 at a psychiatric center in Inner Mongolia, China. Family caregivers of adolescents with MDD were recruited using convenience sampling from the center’s outpatient clinics and inpatient wards. Adolescents’ MDD diagnoses were made by attending psychiatrists during routine clinical care according to ICD-10 criteria and were extracted from the medical records for eligibility screening.
For each eligible adolescent, one primary family caregiver who met the inclusion criteria was approached in person, informed about the study, and invited to participate on a voluntary basis. Paper-and-pencil questionnaires were distributed and completed on site. Caregivers filled in the questionnaires independently; when caregivers had difficulty reading or writing, a trained investigator read the items aloud and recorded the responses without offering guidance. In total, 350 questionnaires were distributed and 308 were returned complete and valid, yielding a response rate of 88%.
Inclusion and exclusion criteria for adolescent patients with depression
Inclusion criteria: (1) meeting the diagnostic criteria for depression according to the International Classification of Diseases, Tenth Edition (ICD-10); (2) aged 12–18 years.
Exclusion criteria: (1) presence of concurrent neurological disorders or organic brain lesions; (2) unwillingness to complete the questionnaire.
Inclusion and exclusion criteria for family caregivers of adolescents with depression
Inclusion criteria: (1) one primary caregiver (parent or other guardian) was selected from each family, responsible for the main caregiving tasks, and invited to complete the questionnaire; (2) aged ≥ 18 years, with a caregiving duration of at least three months; (3) able to communicate effectively; (4) voluntarily agreed to participate and signed informed consent.
Exclusion criteria: (1) individuals who were remunerated for patient care during the illness episode, such as nursing aides or domestic helpers; (2) caregivers with depression or other psychiatric disorders.
Instruments
Affiliate Stigma Scale (ASS)
This 22-item scale was developed based on cognitive-behavioral theory and evaluates stigma across three dimensions: cognition (7 items), emotion (7 items), and behavior (8 items). It uses a 4-point Likert scale, with higher average scores indicating greater affiliate stigma [22]. Previous research has reported high internal consistency (Cronbach’s α = 0.929 overall; 0.822–0.855 for the subscales) [23].
Social Support Rating Scale (SSRS)
Developed by Xiao Shuiyuan, the SSRS measures three dimensions: objective support (items 2, 6, 7), subjective support (items 1, 3, 4, 5), and support utilization (items 8, 9, 10). Total scores range from 12 to 66, with higher scores indicating stronger perceived support. The Social Support Rating Scale used in this study exhibited strong psychometric properties. Internal consistency was satisfactory, with a Cronbach’s alpha of 0.806. Construct validity was also supported, as indicated by a Kaiser–Meyer–Olkin value of 0.848 and a highly significant Bartlett’s test of sphericity (approximate χ² = 1,415.524, P < 0.001) [24].
Family Assessment Device (FAD)
Adapted by Yuan Hao from the McMaster model for use in Chinese populations aged ≥ 12, this scale assesses family functioning. It uses a 4-point Likert scale across six dimensions. Total scores range from 12 to 48, with higher scores indicating worse functioning. An average item score ≥ 2.0 or a total score ≥ 24 suggests dysfunctional family functioning (Cronbach’s α = 0.78) [25].
Simplified coping style Questionnaire(SCSQ)
Developed by Xie Yaning, this 20-item tool assesses how individuals respond to stress. It includes two subscales: positive coping (12 items) and negative coping (8 items), both scored on a 4-point Likert scale. Higher scores indicate greater use of that coping style. The scale demonstrates high internal consistency (positive coping α = 0.89; negative coping α = 0.78) [26].The Chinese version of the Simple Coping Style Questionnaire also demonstrated good reliability and validity [27].
Demographic data
A comprehensive review of the literature on affiliate stigma was conducted in the preliminary stage to identify and summarize its influencing factors. On this basis, the research team engaged in in-depth discussions and consulted experts in the field. Finally, a self-designed questionnaire was developed by the members of the research team. The demographic data collected from patients included gender, age, and whether the illness was a first episode. The demographic data collected from family caregivers included occupation, gender, educational level, marital status, long-term place of residence, average monthly household income per capita, and duration of caregiving.
Statistical analysis
All data were entered into an Excel database, and statistical analyses were performed using SPSS 26.0 and AMOS 24.0. Categorical variables were expressed as frequencies and percentages, while normally distributed continuous variables were presented as mean ± standard deviation (±s). For normally distributed data, between-group comparisons were conducted using independent-sample t tests or one-way analysis of variance. For skewed data, nonparametric tests were applied, and categorical variables were compared using the chi-square test. In addition, multiple regression analysis was employed to examine factors influencing affiliate stigma among family caregivers of adolescents with MDD, with predictors selected from variables that were statistically significant in the univariate analyses. Regression assumptions were examined using histograms and normal probability plots of standardized residuals to assess normality, and plots of standardized residuals versus predicted values to assess homoscedasticity. These diagnostics suggested that the residuals were approximately normally distributed with no obvious heteroscedasticity. Structural equation modeling was conducted using AMOS 24.0 to construct a model of factors influencing affiliate stigma, evaluate model fit, and explore the internal relationships and pathways among the influencing factors. Maximum likelihood estimation was applied given the relatively large sample size and the approximate normality of the observed scale scores.
In this study, all Cronbach's alpha values were above 0.8, indicating satisfactory reliability. Furthermore, the skewness and kurtosis values were examined; the skewness values were less than 1, and the kurtosis values were less than 3, indicating that the data distribution conformed to a normal distribution Table 1.
Table 1.
Cronbach α (N = 308)
| Overall Dimensions | Sub-dimensions | Items | Cronbach α | Total Cronbach α |
|---|---|---|---|---|
| Social Support | Objective Support | 3 | 0.846 | 0.806 |
| Subjective Support | 4 | 0.910 | ||
| Support Utilization | 3 | 0.827 | ||
| Family Functioning | 12 | 0.911 | ||
| Coping Style | Positive Coping | 12 | 0.876 | 0.903 |
| Negative Coping | 8 | 0.855 | ||
| Affiliate Stigma | Cognition Dimension | 7 | 0.828 | 0.915 |
| Emotion Dimension | 7 | 0.839 | ||
| Behavior Dimension | 8 | 0.832 |
Results
General characteristics of adolescents with MDD and their caregivers
A total of 308 adolescents with MDD and their respective caregivers were included in this study. Tables 2 and 3 summarize their demographic characteristics. Among the adolescent patients, males and females were almost equally distributed, with the largest proportion were 14 years old (21.43%). More than half of the patients were experiencing their first depressive episode. Regarding caregivers, the majority were female (65.26%) and lived in urban areas (85.06%). Over half had provided care for less than one year (57.47%).
Table 2.
Demographic characteristics of adolescent patients (N = 308)
| Variable | Category | Frequency (%) |
|---|---|---|
| Gender | Male | 150 (48.70%) |
| Female | 158 (51.30%) | |
| Age | 12 | 15 (4.87%) |
| 13 | 44 (14.29%) | |
| 14 | 66 (21.43%) | |
| 15 | 59 (19.16%) | |
| 16 | 46 (14.94%) | |
| 17 | 37 (12.01%) | |
| 18 | 41 (13.31%) | |
| First Episode | Yes | 166 (53.90%) |
| No | 142 (46.10%) |
Table 3.
Demographic characteristics of family caregivers (N = 308)
| Variable | Category | Frequency (%) |
|---|---|---|
| Gender | Male | 107 (34.74%) |
| Female | 201 (65.26%) | |
| Residence | Rural | 46 (14.94%) |
| Urban | 262 (85.06%) | |
| Occupation | Farmer | 29 (9.42%) |
| Worker | 110 (35.71%) | |
| Retired/Unemployed | 27 (8.77%) | |
| Business/Government/Other | 142 (46.10%) | |
| Education | Junior High or Below | 82 (26.62%) |
| High School/Vocational | 125 (40.58%) | |
| Associate/Bachelor | 90 (29.22%) | |
| Postgraduate or Above | 11 (3.57%) | |
| Marital Status | Married | 291 (94.48%) |
| Unmarried | 10 (3.25%) | |
| Divorced | 7 (2.27%) | |
| Monthly Income (¥) | < 3800 | 49 (15.91%) |
| 3800–5000 | 133 (43.18%) | |
| 5000–8000 | 58 (18.83%) | |
| ≥ 8000 | 68 (22.08%) | |
| Duration of Care | < 1 year | 177 (57.47%) |
| 1–3 years | 98 (31.82%) | |
| > 3 years | 33 (10.71%) |
Scores of affiliate stigma, social support, family functioning, and coping styles
The Family Functioning scores of the 308 caregivers ranged from 18 to 48, with an average total score of 41.545. According to the McMaster family functioning model, a mean item score ≥ 2 or a total score ≥ 24 was considered indicative of unhealthy family functioning, suggesting that most caregivers in this study perceived their family functioning as unhealthy Table 4.
Table 4.
Scores on the family functioning scale
| Variable | Score Range | Observed Range | Total Score ( M ± SD ) | Item Mean Score ( M ± SD ) |
|---|---|---|---|---|
| Total Score | 12–48 | 18–48 | 41.545 ± 6.809 | 3.462 ± 0.567 |
Tables 5, 6 and 7 present the score distributions for affiliate stigma, social support, and coping styles, respectively.
Table 5.
Scores on the affiliate stigma scale
| Variable | Score Range | Observed Range | Total Score ( M ± SD ) | Item Mean Score ( M ± SD ) |
|---|---|---|---|---|
| Total Score | 22–88 | 32–88 | 74.922 ± 9.834 | 3.406 ± 0.447 |
| Cognitive Dimension | 7–28 | 11–28 | 23.792 ± 3.758 | 3.399 ± 0.537 |
| Emotional Dimension | 7–28 | 9–28 | 23.519 ± 3.826 | 3.360 ± 0.547 |
| Behavioral Dimension | 8–32 | 11–32 | 27.610 ± 3.844 | 3.451 ± 0.481 |
Table 6.
Scores on the social support rating scale
| Variable | Score Range | Observed Range | Total Score ( M ± SD ) | Item Mean Score ( M ± SD ) |
|---|---|---|---|---|
| Total Score | 12–66 | 12–45 | 22.958 ± 7.819 | 1.640 ± 0.559 |
| Subjective Support | 8–32 | 8–32 | 14.078 ± 6.262 | 1.760 ± 0.783 |
| Objective Support | 1–22 | 1–10 | 4.003 ± 2.044 | 1.334 ± 0.681 |
| Support Utilization | 3–12 | 3–12 | 4.877 ± 2.054 | 1.626 ± 0.685 |
Table 7.
Scores on the simplified coping style questionnaire
| Variable | Score Range | Observed Range | Total Score ( M ± SD ) | Item Mean Score ( M ± SD ) |
|---|---|---|---|---|
| Positive Coping | 0–36 | 5–36 | 25.614 ± 6.335 | 2.134 ± 0.528 |
| Negative Coping | 0–24 | 3–24 | 18.578 ± 4.425 | 2.322 ± 0.553 |
Univariate analysis of affiliate stigma scores
Univariate analyses showed that Caregiver gender, Education level, Marital status, Monthly household income and whether the illness was a first episode, showed significant associations with affiliate stigma scores (P < 0.05). Specifically, female caregivers reported higher affiliate stigma scores (78.58 ± 8.02) than male caregivers (68.05 ± 9.25). Caregivers with higher education levels had higher stigma scores, with postgraduate or above reporting 79.91 ± 4.99 compared with 70.59 ± 10.11 among those with high school or vocational education. Unmarried (81.70 ± 5.12) and divorced caregivers (81.71 ± 4.72) reported higher stigma than married caregivers (74.53 ± 9.91). Caregivers from households with monthly incomes ≥ 8000 ¥ had higher stigma scores (79.59 ± 6.01) compared with those earning 3800–5000 ¥ (70.56 ± 9.62). Finally, caregivers of patients experiencing a first episode reported higher stigma (81.77 ± 2.49) than those caring for patients with recurrent illness (66.92 ± 9.14). Detailed comparisons are presented in Table 8.
Table 8.
Differences in affiliate stigma scores by demographic characteristics (N = 308)
| Variable | Category | Affiliate Stigma Score ( M ± SD ) | t / F | P |
|---|---|---|---|---|
| Caregiver gender | Male | 68.05 ± 9.25 | -10.397 | < 0.001 |
| Female | 78.58 ± 8.02 | |||
| Residence | Rural | 73.43 ± 11.48 | -0.976 | 0.333 |
| Urban | 75.18 ± 9.52 | |||
| Occupation | Farmer | 73.83 ± 11.21 | 2.174 | 0.091 |
| Worker | 76.46 ± 8.72 | |||
| Retired/Unemployed | 73.59 ± 10.36 | |||
| Business/Government/Other | 73.44 ± 10.94 | |||
| Education | Junior high or below | 79.39 ± 6.85 | 17.698 | < 0.001 |
| High school / Vocational | 70.59 ± 10.11 | |||
| Associate / Bachelor | 76.26 ± 9.80 | |||
| Postgraduate or above | 79.91 ± 4.99 | |||
| Marital status | Married | 74.53 ± 9.91 | 4.375 | <0.05 |
| Unmarried | 81.70 ± 5.12 | |||
| Divorced | 81.71 ± 4.72 | |||
| Monthly household income (¥) | < 3800 | 81.27 ± 3.75 | 25.804 | < 0.001 |
| 3800–5000 | 70.56 ± 9.62 | |||
| 5000–8000 | 74.10 ± 12.11 | |||
| ≥ 8000 | 79.59 ± 6.01 | |||
| Duration of care | < 1 year | 74.85 ± 10.15 | 1.231 | 0.293 |
| 1–3 years | 74.24 ± 10.17 | |||
| > 3 years | 77.33 ± 6.36 | |||
| Patient gender | Male | 74.75 ± 10.29 | 0.095 | 0.758 |
| Female | 75.10 ± 9.36 | |||
| Patient age | 12 years | 74.53 ± 7.88 | 1.246 | 0.283 |
| 13 years | 76.07 ± 8.37 | |||
| 14 years | 75.88 ± 10.63 | |||
| 15 years | 72.51 ± 12.19 | |||
| 16 years | 73.67 ± 10.82 | |||
| 17 years | 77.14 ± 6.31 | |||
| 18 years | 75.17 ± 7.79 | |||
| Patient: first episode | Yes | 81.77 ± 2.49 | -18.783 | < 0.001 |
| No | 66.92 ± 9.14 |
Multiple linear regression analysis of influencing factors
We performed multiple linear regression analysis to identify independent predictors of affiliate stigma. Variables that were significant in univariate or correlation analyses we entered them as candidate predictors. The regression equation was as follows:
Affiliate Stigma Score = 2.6 + 0.081*( Marital status) + 0.541*( Patient first episode)-0.066*( Subjective Support) -0.06*( Support Utilization) + 0.099*( Family Functioning)-0.079*( Positive Coping) + 0.114*( Negative Coping).
Together, these variables explained 65.5% of the variance in affiliate stigma scores (adjusted R² = 0.655). The D-W statistic is 2.142, and the VIF is less than 3; therefore, there are no autocorrelation or multicollinearity problems in this analysis Table 9 and 10.
Table 9.
Coding of variables for multiple linear regression
| Factor | Variable Name | Coding |
|---|---|---|
| Caregiver gender | X1 | Male = 0; Female = 1 |
| Caregiver education level | X2 | Junior high or below = 1; High school/vocational = 2; Associate/Bachelor = 3; Postgraduate or above = 4 |
| Marital status | X3 | Married = 1;Unmarried = 2༛Divorced = 3 |
| Caregiver monthly household income | X4 | < 3800 = 1; 3800–5000 = 2; 5000–8000 = 3; ≥8000 = 4 |
| Patient first episode | X5 | Yes = 1; No = 0 |
| Objective support | X6 | Actual measured value |
| Subjective support | X7 | Actual measured value |
| Support utilization | X8 | Actual measured value |
| Family functioning | X9 | Actual measured value |
| Positive coping | X10 | Actual measured value |
| Negative coping | X11 | Actual measured value |
Table 10.
Multiple linear regression analysis of factors associated with affiliate stigma (N = 308)
| Constant | B (Unstandardized) | Std. Error | Beta (Standardized) | t | P | VIF | Tolerance |
|---|---|---|---|---|---|---|---|
| 2.6 | 0.15 | - | 17.327 | 0.000*** | - | - | |
| Marital status | 0.081 | 0.047 | 0.086 | 1.918 | 0.047* | 2.185 | 0.458 |
| Patient first episode | 0.541 | 0.051 | 0.605 | 10.689 | 0.000*** | 2.780 | 0.360 |
| Subjective Support | -0.066 | 0.022 | -0.115 | -3.036 | 0.003** | 1.251 | 0.799 |
| Support Utilization | -0.06 | 0.024 | -0.092 | -2.538 | 0.012* | 1.131 | 0.884 |
| Family Functioning | 0.099 | 0.03 | 0.126 | 3.342 | 0.001*** | 1.241 | 0.806 |
| Positive Coping | -0.079 | 0.036 | -0.094 | 2.199 | 0.029* | 1.583 | 0.632 |
| Negative Coping | 0.114 | 0.034 | 0.142 | 3.346 | 0.001*** | 1.558 | 0.642 |
R² = 0.655; Adjusted R² = 0.647; F(7,300) = 81.281, p < 0.001; Durbin-Watson = 2.142
Path analysis of influencing factors
We used structural equation modeling (SEM) with maximum likelihood estimation (MLE) to test the hypothesized mediation model. Model fit indices indicated an acceptable fit (χ² = 2431.24, df = 1394,; χ²/df = 1.744; RMSEA = 0.075; CFI = 0.905; GFI = 0.914;IFI = 0.916;TLI = 0.913), suggesting the model has reasonable explanatory power.
Based on the mediation test results shown in Tables 11 and 12 , social support influenced caregivers’ affiliate stigma through both direct and indirect pathways, and both mediators demonstrated partial mediation. In the pathway Social Support → Family Functioning → Affiliate Stigma, social support significantly predicted family functioning (X→M: effect size = − 0.433, 95% CI [− 0.536, − 0.329], P < 0.001), and family functioning in turn significantly predicted affiliate stigma (M→Y: effect size = 0.15, 95% CI [0.078, 0.223], P < 0.001). The indirect effect through family functioning was significant (indirect effect = − 0.065, 95% CI [− 0.128, − 0.041], P = 0.004), indicating that greater social support may reduce affiliate stigma partly by improving family functioning. In the pathway Social Support → Coping Style → Affiliate Stigma, social support also significantly predicted coping style (X→M: effect size = − 0.229, 95% CI [− 0.321, − 0.137], P < 0.001), and coping style significantly predicted affiliate stigma (M→Y: effect size = 0.413, 95% CI [0.331, 0.494], P < 0.001). The indirect effect via coping style was likewise significant (indirect effect = − 0.095, 95% CI [− 0.174, − 0.068], P < 0.001), suggesting that social support can also lower affiliate stigma in part by shaping coping style. Importantly, the direct effect of social support on affiliate stigma remained significant (direct effect = − 0.231, 95% CI [− 0.306, − 0.156], P < 0.001), and the total effect was − 0.391 (95% CI [− 0.469, − 0.312], P < 0.001) Figure 1.
Table 11.
Mediation effect test results
| Items | Effect size | 95% CI | P | Conclusion | ||
| LCL | UCL | |||||
| Social Support = > Family Functioning = > Affiliate Stigma | Indirect effect | -0.065 | -0.128 | -0.041 | 0.004** | Partial mediation |
| Social Support = > Family Functioning | X = > M | -0.433 | -0.536 | -0.329 | 0.000*** | |
| Family Functioning = > Affiliate Stigma | M = > Y | 0.150 | 0.078 | 0.223 | 0.000*** | |
| Social Support = > Affiliate Stigma | Direct effect | -0.231 | -0.306 | -0.156 | 0.000*** | |
| Social Support = > Affiliate Stigma | Total effect | -0.391 | -0.469 | -0.312 | 0.000*** | |
| Social Support = > Coping Style = > Affiliate Stigma | Indirect effect | -0.095 | -0.174 | -0.068 | 0.000*** | Partial mediation |
| Social Support = > Coping Style | X = > M | -0.229 | -0.321 | -0.137 | 0.000*** | |
| Coping Style = > Affiliate Stigma | M = > Y | 0.413 | 0.331 | 0.494 | 0.000*** | |
| Social Support = > Affiliate Stigma | Direct effect | -0.231 | -0.306 | -0.156 | 0.000*** | |
| Social Support = > Affiliate Stigma | Total effect | -0.391 | -0.469 | -0.312 | 0.000*** | |
Table 12.
Model fit indices
| Index | χ² | df | χ²/df | RMSEA | CFI | GFI | IFI | TLI |
|---|---|---|---|---|---|---|---|---|
| Value | 2539.654 | 1394 | 1.744 | 0.075 | 0.905 | 0.914 | 0.916 | 0.913 |
Fig. 1.
Structural model of the relationships among social support, family functioning, coping style, and affiliate stigma. Standardized path coefficients are shown; * P<0.05, ** P<0.01, *** P<0.001
Overall, these findings suggest that social support affects affiliate stigma both directly and indirectly, with family functioning and coping style serving as partial mediators in these relationships. The results underscore the importance of considering these mediators in understanding how social support influences affiliate stigma and highlight the potential for interventions that target family functioning and coping strategies to reduce affiliate stigma.
Discussion
Current status of affiliate stigma among caregivers
In this study, the mean affiliate stigma score among family caregivers was 74.922 ± 9.834, indicating that caregivers of adolescents with MDD commonly experienced moderate-to-high levels of stigma. This value was slightly lower than that reported by Chen et al. [28], but still indicated that a majority of caregivers experienced at least mild stigma, particularly in social interactions where exclusion and discrimination may be perceived. The ongoing dissemination of mental health information through internet platforms and public health education may partly explain the slightly lower scores, as increased awareness can reduce internalized stigma. Moreover, new media such as short videos have become influential channels for health education; when such media present relatable protagonists, they may be particularly effective at reducing stigma [29].
Among the three subdimensions of affiliate stigma, the behavioral dimension showed the highest score (27.610 ± 3.844), indicating that stigma-related experiences were most prominently manifested in caregivers’ behavioral responses. This finding suggests that caregivers may engage in avoidance behaviors, conceal the adolescent’s mental illness, restrict social interactions, or delay help-seeking in order to prevent anticipated discrimination or social judgment. Such behavioral adaptations reflect the internalization of public stigma into daily caregiving practices and social functioning. Over time, these stigma-driven behaviors may restrict social participation, reduce the utilization of social support, and delay help-seeking behaviors [30].
This study showed that the proportion of family members of patients with mental disorders who experienced stigma was higher than that of the patients themselves, which is generally consistent with the findings of Elafros MA [31]. A possible explanation is that MDD is characterized by a long disease course and frequent relapse, leading caregivers to lose confidence in the patient’s recovery. In the context of traditional Chinese culture, mental health problems are often stigmatized, and caregivers are subject to greater prejudice and caregiving burden in their interpersonal interactions. They may view having a family member with MDD as a source of shame, thereby experiencing relatively high levels of affiliate stigma [32, 33]. Previous studies have indicated that the greater the misunderstanding and prejudice toward MDD, the stronger the affiliate stigma perceived by family caregivers [30].
Taken together, these findings suggest that affiliate stigma is not only an individual psychological experience but also closely intertwined with broader social and cultural factors. Addressing affiliate stigma may therefore require attention at multiple levels, including public education, community attitudes, and health system responses. In addition to focusing on symptom management and patient recovery, healthcare professionals may need to be attentive to the stigma experienced by family caregivers and consider providing more targeted informational and emotional support. Such efforts could help mitigate caregivers’ adverse psychological reactions, although future longitudinal and intervention studies are needed to determine which strategies are most effective.
Factors associated with affiliate stigma
This study identified multiple sociodemographic and psychosocial predictors of affiliate stigma, including marital status, patient’s first-episode status, social support, family functioning, and coping styles.
Marital status: Caregivers’ affiliate stigma differed significantly by marital status (P < 0.05), aligning with previous research suggesting that family role structure and available spousal support can shape caregivers’ stigma experiences [34, 35]. Married caregivers may experience lower affiliate stigma when emotional and instrumental support from a partner buffers caregiving stress and reduces feelings of isolation. In contrast, unmarried/divorced/widowed caregivers often shoulder caregiving demands more independently and may face greater economic strain and reduced daily support, which can heighten perceived social judgment and internalized self-blame [36, 37]. These findings underscore marital status as an important social-context factor linked to caregivers’ stigma and highlight the potential value of strengthening family and partner-based support resources.
Social support: Perceived social support was negatively correlated with affiliate stigma (P < 0.05), consistent with the results of Ya Wei et al. [38]. One possible explanation is the long-standing lack of systematic attention to adolescent depression from schools, social welfare organizations, and governmental agencies, which may leave caregivers facing substantial economic and psychological burdens. The limited assistance provided by communities and public organizations may be insufficient to alleviate these pressures, thereby coinciding with higher levels of perceived stigma. Social support is widely regarded as a key protective factor that can buffer negative emotions such as anxiety, depression, and shame [39]. When this external resource is lacking, persistent prejudice against mental illness—exacerbated by inadequate health education—may further reduce the support caregivers perceive, reinforce experiences of discrimination and exclusion, and be accompanied by higher affiliate stigma [40]. Over time, caregivers who maintain a caregiving role in the context of low social support may therefore be at greater risk of more severe internalized stigma.
First episode: Caregivers of adolescents experiencing a first depressive episode reported higher affiliate stigma than those whose children had recurrent episodes. A plausible interpretation is that the sudden onset of illness, combined with a lack of prior caregiving experience, makes it more difficult for caregivers to understand and accept the diagnosis. As a result, they may be more prone to anxiety, depressed mood, and uncertainty, which can disrupt normal work and daily life and may contribute to social withdrawal or self-isolation for both patients and families. In these circumstances, caregivers may be more likely to interpret the illness in stigmatizing terms, which not only affects their own mental health but may also place strain on the caregiver–patient relationship and coincide with impaired family functioning [41]. Clinically, it may therefore be important for healthcare professionals to provide early, clear information and emotional support to caregivers of first-episode patients, encourage them to acknowledge and manage stigma-related reactions, and support families in facing the illness collaboratively.
Family functioning: Poor family functioning was positively associated with affiliate stigma.This finding is consistent with the results of Liu et al. [42]. A plausible explanation is that well-functioning families are able to distribute caregiving tasks more effectively and share responsibilities positively, thereby reducing caregivers’ stress. In contrast, family dysfunction may leave caregivers feeling isolated and unsupported, which can exacerbate affiliate stigma. A harmonious and supportive family environment can buffer against the development of mental health problems, acting as a cushion that mitigates the negative impact of stress when individuals face challenges or setbacks [43, 44]. From a clinical perspective, healthcare professionals should strengthen caregiver education to ensure continuity of care after hospital discharge. Joint participation in disease management can enhance family cohesion and reduce affiliate stigma in both patients and caregivers.
Coping style: Caregivers’ coping styles were also closely related to their levels of affiliate stigma. Caregivers with stronger coping resources are more likely to adopt active and positive strategies, which can help them manage stress more effectively. In contrast, prolonged reliance on avoidant or passive coping may be linked to negative consequences in multiple domains of patients’ lives, including reluctance to reintegrate into family or social environments. Li et al. [45] noted that caregivers who rely heavily on negative coping tend to experience more depressed mood and fatalistic attitudes, and may struggle to balance caregiving responsibilities with self-care, leading to withdrawal from normal social activities. Clinically, nurses and other healthcare professionals can play a role in helping caregivers recognize unhelpful coping patterns, providing psychoeducation on more adaptive strategies, and encouraging shared care within the family, which may improve cohesion and be associated with lower levels of affiliate stigma.
Pathways linking social support and affiliate stigma
Our mediation analysis indicated that social support influenced affiliate stigma among family caregivers through both direct and indirect pathways. Specifically, social support had a significant direct negative effect on affiliate stigma (direct effect = − 0.231, 95% CI [− 0.306, − 0.156], P < 0.001) and also reduced stigma indirectly via two partially mediating mechanisms. The indirect effect through family functioning was significant (indirect effect = − 0.065, 95% CI [− 0.128, − 0.041], P = 0.004), and the indirect effect through coping style was also significant (indirect effect = − 0.095, 95% CI [− 0.174, − 0.068], P < 0.001). The total effect of social support on affiliate stigma was − 0.391 (95% CI [− 0.469, − 0.312], P < 0.001). Together, these findings suggest that social support may alleviate caregivers’ affiliate stigma not only directly, but also by improving family functioning and shaping coping style, underscoring multiple complementary pathways through which social resources can mitigate internalized stigma.
The level of social support available to family caregivers emerged as a meaningful correlate of affiliate stigma, such that greater perceived support was associated with lower stigma scores. Previous studies have similarly reported that caregivers with higher levels of social support tend to report less affiliate stigma, possibly because external support fosters a sense of understanding, acceptance, and shared burden, which may help to offset the negative emotions triggered by social stigma [46, 47]. In light of these findings, clinical practice could consider placing greater emphasis on providing caregivers with emotional support and rehabilitation-related guidance—for example, through family support groups, psychoeducational programs, and psychological counseling. At the community level, modern information technologies and new media platforms may be used to broaden the reach of mental health education, enhance public awareness of depression, and reduce prejudicial attitudes, thereby potentially strengthening the social support environment surrounding caregivers.
The first indirect pathway—Social Support → Family Functioning → Affiliate Stigma—suggests that the association between social support and affiliate stigma may be partly accounted for by differences in family functioning. As the primary setting of daily life, the family environment plays a pivotal role in shaping caregivers’ psychological well-being and is closely intertwined with the clinical course of patients [48]. In our data, higher perceived social support was associated with more favorable family functioning, and more favorable family functioning, in turn, was associated with lower levels of affiliate stigma. This pattern is compatible with the notion that families with clearer role allocation, more effective communication, and stronger cohesion may be better able to share caregiving responsibilities and provide mutual emotional support, which can relieve caregiver burden and reduce feelings of being judged or ostracized.
The second indirect pathway—Social Support → Coping Style → Affiliate Stigma—highlights complementary individual-level processes. In this model, greater social support was associated with more adaptive coping, and adaptive coping was associated with lower affiliate stigma. In other words, social resources appear to co-occur with more proactive, problem-focused, and emotion-focused coping strategies among caregivers, which may help them manage stress and resist internalizing stigmatizing attitudes. Existing evidence indicates that adequate social support can mitigate some of the adverse psychological consequences of long-term caregiving, whereas insufficient support may be linked to greater reliance on avoidant or maladaptive coping strategies and, in turn, higher stigma [49]. Given the cross-sectional nature of the present study, these pathways should be interpreted as statistical associations rather than definitive causal mechanisms; nonetheless, they provide a useful framework for generating hypotheses for future longitudinal and intervention research.
Limitations
This study has several limitations that should be considered when interpreting the findings. First, as a single-center investigation focusing on family caregivers of adolescents with MDD, the sample may have been relatively homogeneous in terms of clinical setting and sociodemographic background, which may limit the generalizability of the results to caregivers from other regions, healthcare systems, or cultural contexts. Second, the cross-sectional design precludes causal inference and cannot capture the temporal ordering among social support, family functioning, coping style, and affiliate stigma; it also fails to reflect potential fluctuations in stigma across different phases of illness, treatment, relapse, or recovery. Third, all variables were assessed using self-report questionnaires, which may introduce recall bias and social desirability effects, and may inflate associations due to common method variance. Fourth, although the model incorporated key psychosocial mechanisms, other potentially important factors were not examined, such as symptom severity and chronicity of the adolescent’s depression, caregivers’ own mental health (e.g., depressive symptoms, anxiety, burnout), and caregiving burden. Finally, the findings should be interpreted within the specific cultural context of China, where family-centered values, social norms, and culturally embedded attitudes toward mental illness may shape the manifestation and expression of affiliate stigma. To obtain a more comprehensive and robust understanding of affiliate stigma in this population, future research should employ multicenter, large-sample longitudinal or intervention designs and consider richer contextual and clinical covariates to enhance both internal and external validity.
Future research directions
Building on the present findings, future studies could adopt multicenter, large-sample, and longitudinal designs to enhance generalizability and clarify causal relationships among social support, family functioning, coping styles, and affiliate stigma. Additionally, incorporating clinical variables such as symptom severity, illness chronicity, caregivers’ mental health status, and cultural factors could provide a more comprehensive understanding of factors influencing affiliate stigma. Intervention studies examining targeted strategies at both the family-system and individual coping levels are also warranted to identify effective approaches to reduce affiliate stigma among caregivers.
Conclusion
The findings of this study indicate that affiliate stigma among family caregivers of adolescents with MDD was at a moderately high level and warrants greater attention. The dual mediation suggests that reducing affiliate stigma requires interventions at both the family-system level and the individual coping level.
Acknowledgements
We acknowledge all the family caregivers of adolescents with major depressive disorder in this study, as well as to all the members of the research team and the data collection team.
Abbreviations
- MMD
Major depressive disorder
Authors’ contributions
G.B. and C.X. designed the research. G.B., W.H., G.S. and G.Y. participated in the acquisition, analysis and interpretation of the data. G.B., G.Y. and Z.Z. participated in the writing of the first draft of the paper. C.X. and Y.J. revised the first draft and approved the final draft.All authors agree with the final manuscript and are responsible for all aspects of their work.
Funding
This study was supported by the Science and Technology Project for High-level Clinical Specialty Construction of Public Hospitals in the Capital Region of Inner Mongolia (Grant No. 2024SGGZ052).
Data availability
The data used and analyzed in this study can be obtained from the corresponding author for reasonable reasons.
Declarations
Ethics approval and consent to participate
This study was approved by the Medical Ethics Committee of Inner Mongolia Medical University (No. YKD202402130) and was conducted strictly in accordance with the World Medical Association’s Declaration of Helsinki. All the family caregivers of adolescents participating in the study signed the informed consent form.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Bingyi Guo and Haiyan Wang contributed equally to this work.
Contributor Information
Xuexia Chen, Email: chxx7415@163.com.
Jiaojiao Yang, Email: Yangjiao986@126.com.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data used and analyzed in this study can be obtained from the corresponding author for reasonable reasons.