Association of media portrayals and negative interpersonal experiences with internalized stigma among outpatients with schizophrenia

Abstract

Objective: This study examined factors associated with internalized stigma among community-dwelling individuals with schizophrenia, focusing on associations with negative interpersonal experiences, media representations, and illness duration.

Materials and Methods: A cross-sectional survey was conducted with 80 outpatients at a university hospital using the Japanese version of the Internalized Stigma of Mental Illness Scale (ISMI-10). Associations between self-stigma and treatment duration, negative interpersonal reactions, and perceived discrepancies in media portrayals were analyzed. Binary logistic regression analysis was also performed, adjusting for treatment duration.

Results: The mean treatment duration was 23.6 ± 13.2 years. Internalized stigma was significantly associated with “negative reactions when disclosing illness or symptoms to others” (adjusted odds ratio: 3.88, 95% confidence interval: 1.27–11.87; P=0.018) and “perceived discrepancy between media portrayals of schizophrenia and reality” (adjusted odds ratio: 5.62, 95% confidence interval: 1.78–17.76, P=0.003). The adjusted odds ratio for perceived discrepancy between media portrayals and reality was numerically higher than that for negative interpersonal experiences after adjustment for treatment duration.

Conclusion: Internalized stigma in community-dwelling patients with schizophrenia is associated with negative interpersonal experiences and media-driven stereotypes. The strong link to media portrayal suggests that information dissemination in the digital age may exacerbate self-stigma. Support strategies in rural and local communities should focus on improving media literacy and collaborative efforts with residents to reconstruct social roles for individuals with schizophrenia.

Introduction

Globally, care for individuals with schizophrenia is shifting from hospital-centered models to community-led support systems¹⁾. However, stigma remains a major barrier to successful community living for individuals with schizophrenia. A lack of understanding and misconceptions about mental illnesses generate discrimination and stigma. These patterns tend to cause individuals with schizophrenia to hesitate to seek help or use professional services²⁾, thereby making it difficult to secure employment and housing and build interpersonal relationships within the community³⁾. One report focusing on six Asian countries and regions (China, Hong Kong, Japan, South Korea, Singapore, and Thailand) highlighted the persistent tendency to view patients with schizophrenia as dangerous and aggressive. Furthermore, deep-rooted cultural barriers affect individuals with schizophrenia, such as family stigma, in which the entire family experiences discrimination, and the perception of mental illness as a personal character flaw⁴⁾.

Internalized stigma reduces self-confidence, impairs social functioning, and hinders the daily activities of individuals with schizophrenia⁵⁾. Previous studies have highlighted that direct experiences of discrimination contribute to the development of internalized stigma⁶⁾. Furthermore, there was a strong association between high levels of internalized stigma and lower levels of subjective recovery⁷⁾. Internalized stigma has also been documented in conditions other than schizophrenia, such as epilepsy and multiple sclerosis, where it reduces quality of life, causes psychological distress or depression, and hinders social participation^8,9,10). Generally, individuals living with a disease or disability tend to adapt over time and develop a sense of acceptance. However, there is insufficient evidence on whether internalized stigma diminishes with illness duration. Some studies have indicated that high levels of internalized stigma are present in the early stages of illness onset. Although a correlation between illness duration and caregiver stigma has been demonstrated, this relationship remains understudied in individuals with schizophrenia¹¹⁾. Although it has been suggested that the tendency toward social withdrawal due to stigma intensifies between one and ten years after schizophrenia onset¹²⁾, it remains unclear how illness duration affects stigma levels. Although some reports have suggested a positive correlation between internalized stigma and illness duration¹³⁾, there is a lack of consensus in the literature regarding this relationship.

In recent years, there has been a major shift in the media landscape owing to rapid advancements in digital technology. While television and newspapers were once the main sources of information, the mainstream adoption of smartphones has enabled universal internet access, leading to the deep integration of social networking services (SNS) into daily life. This shift has exponentially increased exposure to negative and unreliable information among individuals with mental illnesses¹⁴⁾. Exposure to harmful SNS content has been linked to poorer mental health outcomes, including depression, anxiety, and suicidal ideation¹⁵⁾.

Although SNS can broaden understanding of mental health, there is a risk that it may increase internalized stigma by trivializing individual struggles or attributing them solely to personal responsibility¹⁶⁾. Depictions of idealized others and subsequent comparisons with one’s own reality can trigger feelings of inadequacy and dissatisfaction in individuals with mental disorders, potentially increasing internalized stigma¹⁷⁾. Conversely, although mental illness disclosures by general users and influencers on SNS are likely to reduce public stigma¹⁸⁾, reports indicate that even in response to disclosures by celebrities, approximately 20% of comments contain stigmatizing content¹⁹⁾. Thus, it is extremely difficult to avoid negative discourse completely in the digital space. Although fragmentary evidence for the link between recent media transformations and internalized stigma is accumulating, there is a lack of clarity regarding how modern media exposure, specifically the perceived discrepancy between media portrayals of schizophrenia and individuals’ own lived experiences, relates to internalized stigma among community-dwelling individuals with schizophrenia.

This study aimed to clarify how individuals with schizophrenia perceive their illness in daily life and to identify the stigmatizing experiences that act as barriers to social participation. A quantitative investigation was conducted to examine the association of negative external reactions and media portrayals with the formation of internalized stigma among these individuals. This research could help to clarify the support challenges in regional practice by identifying the specific psychological and social barriers experienced by individuals living in the community. Furthermore, the findings are expected to help community residents deepen their understanding of schizophrenia, thereby contributing to the creation of a prejudice-free community in which individuals with and without mental illness can coexist.

Materials and Methods

Data collection

1. Participants and selection criteria

This study included outpatients diagnosed with schizophrenia at a university hospital. Of the 172 patients scheduled for visits during the study period, 124 were identified as eligible candidates after applying the following criteria:

The inclusion criteria were as follows: (1) a diagnosis of schizophrenia and (2) receiving outpatient treatment during the study period. The exclusion criteria, as determined by the attending physicians, were (1) comorbid intellectual disability, (2) difficulty responding owing to cognitive impairment, (3) risk of mental state deterioration owing to study participation, and (4) refusal to provide informed consent.

2. Instruments

The survey instrument was an original questionnaire developed based on previous literature to comprehensively assess how community-dwelling individuals with schizophrenia perceive their illness and barriers to social participation. To measure internalized stigma quantitatively, the Japanese version of the Internalized Stigma of Mental Illness (ISMI-10) scale was included in the survey questionnaire. The development process for the questionnaire items comprised the following: (1) a comprehensive literature review^20,21,22); (2) the selection of candidate items; (3) consultations among researchers to ensure face validity, clarity, and alignment with the study objectives; and (4) a pilot test conducted with three clinical psychologists. This preliminary evaluation confirmed the clarity, readability, and relevance of the items to the research themes. Based on the feedback received, minor adjustments were made to the wording to eliminate ambiguity and reduce respondent burden. No important structural flaws were identified, confirming that the final version of the instrument had sufficient face validity for the purposes of this exploratory study. The study period was from December 15, 2025, to February 28, 2026.

Survey items

1. Sociodemographic characteristics

The following sociodemographic characteristics were recorded: age (years) and age group (1: 20s, 2: 30s, 3: 40s, 4: 50s, 5: 60s, 6: 70s, and 7: others). The participants’ clinical and social background characteristics included duration of treatment (years since the first psychiatric consultation, including consultations at other institutions), highest educational attainment (1: junior high school; 2: high school; 3: junior college/vocational school; 4: university), and living arrangements (1: living alone, 2: living with family, 3: living with friends, 4: others). Furthermore, marital status (1: no, 2: yes) and employment status (1: regular employment, 2: on leave, 3: seeking employment, 4: Type-A support for continuous employment [i.e., social welfare support for individuals with disabilities], 5: employment for individuals with disabilities in a general company, 6: consulting at a Public Employment Security Office [i.e., government-run employment consultation service]) were assessed.

2. Internalized stigma

To quantitatively assess the level of internalized stigma among individuals with mental illness, the Japanese version of the 10-item ISMI-10 scale was used. The survey items consisted of the following 10 statements: (1) Mentally ill people tend to be violent, (2) People with mental illness make important contributions to society [reverse-scored], (3) I am not as socially active as I used to be because I might look or behave “weird” as I have a mental illness, (4) Having a mental illness has spoiled my life, (5) I stay away from social situations to protect my family or friends from being embarrassed, (6) People who do not have a mental illness could not possibly understand me, (7) Because I have a mental illness, people ignore me or don’t take me seriously, (8) I can’t contribute anything to society because I have a mental illness, (9) I can lead a good, fulfilling life despite my mental illness [reverse-scored], and (10) Others think that I can’t achieve much in life because I have a mental illness. Each item is rated on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree). After reverse-coding items (2) and (9), the mean score was calculated, with higher scores indicating greater severity of internalized stigma. Permission to use the Japanese version of the scale was obtained from the developer.

3. Negative experiences related to illness and symptoms

The participants’ negative experiences and perceptions of their illness were assessed using five items: “Do you feel that you do not want others to know about your illness or symptoms?” Have you ever been reluctant to talk to others about your illness or symptoms?” Have you ever experienced negative reactions when talking to others about your illness or symptoms?” Have you ever experienced difficulties in interpersonal relationships at work or school because of your illness or symptoms?”, “Do you feel that the portrayal of ‘schizophrenia’ in the media (e.g., newspapers, television, SNS) differs from reality?” Each item was rated on a 4-point Likert scale: (1) Never, (2) Rarely, (3) Often, and (4) Always.

4. Willingness to participate in community activities for stigma reduction

Participants’ willingness to engage in community activities aimed at stigma reduction was assessed using the following three items: “Would you like to participate in activities aimed at reducing biased views and stereotypes toward schizophrenia?”, “If there was an opportunity to discuss with community residents what each person can do to help everyone live in their own way, would you like to participate?”, “Do you want to contribute to the community by utilizing your own abilities and skills?” Each item was rated on a 4-point Likert scale: (1) Disagree, (2) Slightly disagree, (3) Slightly agree, and (4) Agree.

Analysis methods

Descriptive statistics were calculated to analyze the participant characteristics. Mean and standard deviation were used for age and treatment duration, and frequencies and percentages were determined for other categorical variables to confirm their distribution. The ISMI-10 score at the time of the survey was used as the dependent variable. The participants were categorized into two groups: the low internalized stigma group (mean scores 1.00–2.50) and the high internalized stigma group (mean scores 2.51–4.00) based on the classification by Ritsher and Phelan²³⁾.

In this study, the variables were converted into binary categories based on the previous literature and the distribution of the current dataset. Age was dichotomized into two groups based on the median value: younger (<55 years) and older (≥55 years). The duration of treatment was also dichotomized based on the mean value of the dataset: shorter duration (<24 years) and longer duration (≥24 years); this threshold was established as an important cutoff for the analysis. Regarding negative experiences related to illness and symptoms, the 4-point Likert-scale responses were dichotomized into “Absent” (1: Never, 2: Rarely) and “Present” (3: Often, 4: Always). Similarly, for willingness to participate in community activities, responses were converted into binary variables: “No” (including “No” and “Neutral”) and “Yes”. Living arrangements were categorized into “living alone” and “not living alone” (including living with family, friends, or in group homes). Finally, employment status was dichotomized into “unemployed/welfare-based employment” (on leave, seeking employment, or consulting at public employment services) and “competitive/supported employment” (regular employment, Type-A support for continuous employment, or employment in a general company).

Next, binomial logistic regression analysis was performed to explore the factors associated with internalized stigma among patients with schizophrenia. Treatment duration was fixed in the model and two factors were entered using the forced-entry method based on the study’s focus and potential confounding effects: “negative reactions when disclosing illness or symptoms to others” and “perceived discrepancy between media portrayals of schizophrenia and reality”. Before the analysis, the variance inflation factor was calculated to assess multicollinearity. The values ranged from 1.046 to 1.083, indicating no significant multicollinearity. Listwise deletion was used to handle missing data. Consequently, despite varying number of valid responses in the bivariate analyses, the final logistic regression model used a consistent sample size across all variables. All data entry, tabulation, and statistical analyses were conducted using IBM SPSS Statistics for Windows, Version 29.0 (IBM Corp., Armonk, NY, USA). The level of statistical significance was set at P<0.05.

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki (as revised in Fortaleza, 2013) and was approved by the ethics committees of the authors’ affiliated universities (Approval Nos. C225 and 250080). Before participation, all participants were provided with an information sheet describing the purpose of the study, the voluntary nature of participation, a guarantee of anonymity, protection of privacy, and assurance that the decision to participate or not would have no impact on their medical treatment. This was a completely anonymous survey, and no personally identifiable information, such as names or contact details, was collected. Informed consent was defined as placing the completed paper-based questionnaire in a designated collection box or mailing it back. Participants were informed of their right to discontinue responding and refuse participation at any time during the study. However, because the survey was completely anonymous, it was impossible to identify which responses belonged to which participant once the data were submitted. Therefore, the information sheet explicitly stated that data withdrawal after submission was impossible.

Results

1. Participant characteristics

A total of 159 individuals were invited to participate and 85 responses were received. After excluding five responses with substantial missing data, 80 participants were included in the final analysis (valid response rate: 50.3%). The mean age of participants was 52.9 ± 12.8 years, and the mean duration of treatment was 23.6 ± 13.2 years. Regarding sex, 37 participants were men (47.4%), and 41 were women (52.6%). In terms of the highest educational attainment, 44 participants (55.0%) were high school graduates, 17 (21.3%) attended junior college or vocational school, and 14 (17.5%) were university graduates. Regarding living arrangements, 63 participants (79.7%) were living with family and 13 (16.5%) were living alone. In terms of marital status, 53 participants (67.9%) were single and 25 (32.1%) were married. For employment status, 36 participants (60.0%) were categorized as “unemployed/welfare-based employment” (on leave, seeking employment, or consulting at the Public Employment Security Office) and 24 (40.0%) were in “competitive/supported employment” (regular employment or Type-A support for continuous employment) (Table 1).

Table 1. Participant characteristics by internalized stigma level (N=80).

Items		Category	Total		ISMI-10				P-value
					Low internalized stigma group (n=54)		High internalized stigma group (n=26)
			n	%	n	%	n	%
Sociodemographic characteristics
Age (n=80), mean ± SD			52.9	12.8	52.7	12.7	53.2	13.2	0.855a
	Age group (n=80)	<55 years	38	47.5	25	65.8	13	34.2	0.756b
		≥55 years	42	52.5	29	69.0	13	31.0
		20s	4	5.0
		30s	9	11.3
		40s	15	18.8
		50s	27	33.8
		60s	17	21.3
		70s	8	10.0
	Sex (n=78)	Male	37	47.4	25	67.6	12	32.4	0.873b
		Female	41	52.6	27	65.9	14	34.1
Duration of treatment (years since first psychiatric consultation, including at other institutions) (n=76), mean ± SD			23.6	13.2	21.9	12.6	26.7	13.9	0.135a
	Duration of treatment (n=76)	24 years	38	50.0	27	71.1	11	28.9	0.333b
		≥24 years	38	50.0	23	60.5	15	39.5
	Highest educational attainment (n=80)	Junior high school or high school	49	61.3	39	79.6	10	20.4	0.004b
		Junior college/vocational school or university	31	38.8	15	48.4	16	51.6
	Living arrangements (n=79)	Living alone	13	16.5	8	61.5	5	38.5	0.749c
		Others	66	83.5	45	68.2	21	31.8
		Living with family	63	79.7
		Living with friends	1	1.3
		Others (e.g., group homes)	2	2.5
	Marital status (n=78)	No	53	67.9	36	67.9	17	32.1	0.732b
		Yes	25	32.1	16	64.0	9	36.0
	Employment status (n=60)	Other (on leave, seeking employment, employment for individuals with disabilities in a general company, consulting at the Public Employment Security Office)	36	60.0	21	58.3	15	41.7	0.021c
		Regular employment or Type-A support for continuous employment	24	40.0	21	87.5	3	12.5
SMI-10 score, mean ± SD			2.42 ± 0.49		2.15 ± 0.31		2.96 ± 0.31		<0.00a

^aStudent’s t-test, ^bχ² test, ^cFisher’s exact test. ISMI-10: Japanese version of the Internalized Stigma of Mental Illness; SD: standard deviation.

2. Severity of internalized stigma

The mean ISMI-10 total score was 2.42 ± 0.49 (range: 1.0–4.0). Based on the predefined cutoff points, 26 participants (32.5%) were classified into the high internalized stigma group, and 54 participants (67.5%) into the low internalized stigma group.

3. Factors associated with internalized stigma among patients with schizophrenia

Bivariate analysis identified several factors significantly associated with high levels of internalized stigma. A higher prevalence of high internalized stigma was observed among participants whose highest educational attainment was junior college/vocational school or university (16 participants, 51.6%; P=0.004) and those whose employment status was “unemployed/welfare-based employment” (15 participants, 41.7%; P=0.021) (Table 1). Furthermore, significant associations were found for the following items: experiencing difficulties in interpersonal relationships at work or school due to the effects of illness or symptoms (Yes: 24 participants, 52.2%; P<0.001) and perceiving a discrepancy between media portrayals of schizophrenia and reality (Yes: 20 participants, 54.1%; P<0.001) (Table 2).

Table 2. Factors associated with internalized stigma among patients with schizophrenia (N=80).

Items		Category	Total		ISMI-10				P-value
					Low internalized stigma group (n=54)		High internalized stigma group (n=26)
			n	%	n	%	n	%
Negative experiences related to illness and symptoms
	Do you feel that you do not want others to know about your illness or symptoms? (n=80)	No	23	28.7	19	82.6	4	17.4	0.112a
		Yes	57	71.3	35	61.4	22	38.6
	Have you ever felt reluctant to talk to others about your illness or symptoms? (n=80)	No	17	21.3	14	82.4	3	17.6	0.242a
		Yes	63	78.8	40	63.5	23	36.5
	Have you ever received a negative reaction when talking to others about your illness or symptoms? (n=78)	No	49	62.8	39	79.6	10	20.4	0.003a
		Yes	29	37.2	13	44.8	16	55.2
	Have you ever experienced difficulties in interpersonal relationships at work or school due to the effects of your illness or symptoms? (n=79)	No	33	41.8	31	93.9	2	6.1	<0.001a
		Yes	46	58.2	22	47.8	24	52.2
	Do you feel that the portrayal of ‘schizophrenia’ in the media (e.g., newspapers, television, SNS) differs from reality? (n=78)	No	41	52.6	35	85.4	6	14.6	<0.001a
		Yes	37	47.4	17	45.9	20	54.1
Willingness to participate in community activities for stigma reduction
	Would you like to participate in activities aimed at reducing biased views and stereotypes toward schizophrenia? (n=79)	No or Neutral	71	89.9	47	66.2	24	33.8	1.000a
		Yes	8	10.1	6	75.0	2	25.0
	If there was an opportunity to discuss with community residents what each person can do to help everyone live in their own way, would you like to participate (n=80)	No or Neutral	67	83.8	43	64.2	24	35.8	0.204a
		Yes	13	16.3	11	84.6	2	15.4
	Do you want to contribute to the community by utilizing your own abilities and skills? (n=80)	No or Neutral	45	56.3	28	62.2	17	37.8	0.337a
		Yes	35	43.8	26	74.3	9	25.7

^aFisher’s exact test. ISMI-10: Japanese version of the Internalized Stigma of Mental Illness.

4. Independent predictors of high internalized stigma

The binomial logistic regression analysis identified two factors significantly associated with internalized stigma among patients with schizophrenia: “negative reactions when disclosing illness or symptoms to others” (adjusted odds ratio [AOR]: 3.88, 95% confidence interval [CI]: 1.27–11.87; P=0.018) and “perceived discrepancy between media portrayals of schizophrenia and reality” (AOR: 5.62, 95% CI: 1.78–17.76; P=0.003) (Table 3).

Table 3. Logistic regression analysis of factors associated with high internalized stigma (n=74).

Items	Category	COR	95% CI		AOR	95% CI		P-value
			Lower limit	Upper limit		Lower limit	Upper limit
Duration of treatment	<24 / ≥24 (ref)	1.60	0.62	4.17	1.02	0.33	3.14	0.980
Negative reactions when disclosing illness or symptoms to others	Yes / No (ref)	4.80	1.75	13.17	3.88	1.27	11.87	0.018
Perceived discrepancy between media portrayals of schizophrenia and reality	Yes / No (ref)	6.86	2.33	20.22	5.62	1.78	17.76	0.003

Binomial logistic regression analysis. AOR: adjusted odds ratio; COR: crude odds ratio; CI: confidence interval.

Discussion

This study suggests that among outpatients with schizophrenia, negative reactions to the disclosure of illness or symptoms and perceived discrepancies between media portrayals and reality are major contributors to internalized stigma.

Notably, these associations remained significant even after adjusting for the duration of treatment, with negative reactions from others increasing the likelihood of high internalized stigma by approximately 3.9 times (AOR: 3.88) and perceived discrepancy regarding media portrayals by approximately 5.6 times (AOR: 5.62).

Various studies have highlighted the association between negative reactions from others and internalized stigma. Specifically, the possibility that social stigma and discriminatory attitudes are incorporated into an individual’s self-concept, potentially transforming into internalized stigma, has been discussed^{24, 25)}. Previous research has suggested that negative experiences such as rude jokes or verbal abuse are associated with internalized stigma²⁶⁾. Furthermore, the perception of negative reactions from others may be linked to direct undermining of an individual’s internal self-evaluation²⁷⁾. In the present study, the experience of negative reactions from others was significantly associated with higher internalized stigma, even after adjusting for treatment duration. This finding suggests that the effects of negative verbal or attitudinal responses from others may persist over time, regardless of illness duration or time since schizophrenia diagnosed.

A perceived discrepancy between media portrayals of schizophrenia (e.g., newspapers, television, or social media) and reality was significantly associated with higher internalized stigma. Media portrayals may play a role in how individuals with schizophrenia perceive their social standing, and how they are defined by society. The persistent emphasis on stereotypes of people with schizophrenia in the media, such as the assumption that they are unpredictable or dangerous^28,29,30), may lead individuals to perceive a gap between their own lived experiences and public depictions. This recognition, in turn, may be associated with an increased sense of social alienation and the reinforcement of internalized stigma—the feeling that “This is how the world sees me”. Notably, with the rapid proliferation of digital devices in recent years, the frequency of exposure to negative or unreliable information through social media has increased^{31, 32)}. In the present study, the AOR for perceived discrepancies regarding media portrayals (5.62) was higher than that for negative reactions from others (3.88). This result suggests that structural changes in information dissemination driven by the growth of the Internet and social media are increasingly relevant to the reinforcement of internalized stigma among individuals with schizophrenia.

These findings have significant clinical implications. This study revealed that negative interpersonal experiences and perceived discrepancies in media portrayals significantly contribute to internalized stigma among community-dwelling individuals with schizophrenia. The social and clinical consequences of this increased burden are significant. A comprehensive systematic review by Clement et al. demonstrated that mental health-related stigma, particularly internalized stigma, is a major barrier that negatively affects help-seeking behavior³³⁾. Internalizing negative stereotypes may delay seeking professional help and hinder recovery and community living. Our findings highlight the urgent need to address media-driven stereotypes and negative social attitudes to alleviate the psychological distress of individuals with schizophrenia and promote timely help-seeking and sustained engagement with community-based psychiatric services.

This study has several limitations. First, causality cannot be proven due to the cross-sectional design. For instance, while a perceived discrepancy in media portrayal may increase internalized stigma, it is also possible that individuals with higher internalized stigma are more likely to perceive media reports negatively, suggesting a potential bidirectional influence. Second, the sample size was limited to 80 participants (n=74 for multivariate analysis), who were recruited using convenience sampling from the outpatient clinic of a single university hospital. Consequently, the statistical power may not be sufficient to permit a broad generalization of the findings. Third, while the ISMI-10 scale was used to measure internalized stigma, other items (such as those used to assess negative reactions from others and perceived discrepancies in media portrayals) were original survey items developed based on previous literature. Although this was a pilot study in which the face validity of the items was assessed by clinical psychologists, the internal consistency and test–retest reliability were not evaluated, and the results may have been affected by measurement error. Fourth, social desirability bias may have influenced the data collection process. Because survey participation was requested directly during outpatient visits, with the cooperation of attending physicians, participants may have felt unintended psychological pressure, which may have skewed the responses toward a more positive direction. Additionally, selection bias cannot be ruled out as the sample likely consisted of individuals whose symptoms were relatively stable and who were able to cooperate with the survey. Finally, because the study relied on self-reported Likert scale responses based on individual experiences, recall bias is possible. These limitations should be addressed in future studies to validate our findings further.

Conclusion

This study found that internalized stigma among community-dwelling individuals with schizophrenia is linked to negative reactions from others and a perceived discrepancy between media portrayals and reality, regardless of illness duration. The perceived discrepancy between media portrayals and reality may be more influential than negative interpersonal experiences. These findings suggest that structural changes in information dissemination in the current digital society may have a substantial effect on the internalized stigma of individuals with mental illnesses. Therefore, to mitigate internalized stigma in the community, it is essential not only to increase media literacy but also promote collaborative initiatives involving both service users and community residents to reconstruct social roles and foster mutual understanding.

Conflict of interest

The authors declare that they have no conflicts of interest.

Funding information

This work was supported by the Public Promoting Association of Ogawa YK Foundation.

Ethics approval and consent to participate

This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committees of Kanazawa Medical University and University of Kochi (Approval Nos. C225 and 250080). All participants were informed of the study’s purpose, the voluntary nature of their participation, and the protection of their anonymity and privacy. As this was a completely anonymous survey that did not collect any personally identifiable information, informed consent was obtained from the participants after completion and submission of the questionnaire. The information sheet explicitly stated that, owing to the anonymous nature of the data, withdrawal of consent after submission was not possible. The consent procedure and protocol were approved by the ethics committee.

Consent for publication

All authors consent to the submission of this manuscript to the Journal of Rural Medicine.

Author contributions

Conceptualization, R. Hashimoto; Methodology, R. Hashimoto and H. Nakai; Validation, R. Hashimoto and H. Nakai; Formal analysis, R. Hashimoto and H. Nakai; Investigation, R. Hashimoto, Y. Nitta, and Y. Furukawa; Resources, R. Hashimoto, Y. Nitta, Y. Furukawa, and T. Uehara; Data curation, R. Hashimoto and H. Nakai; Writing—original draft preparation, R. Hashimoto and H. Nakai; Writing—review and editing, R. Hashimoto, H. Nakai, Y. Nitta, Y. Furukawa, and T. Uehara; Visualization, R. Hashimoto and H. Nakai; Supervision, T. Uehara; Project administration, H. Nakai. All authors have read and approved the final version of the manuscript.

Funding Statement

This work was supported by the Public Promoting Association of Ogawa YK Foundation.

Data availability statement

The datasets generated during this study are not publicly available to ensure the privacy of participants but are available from the corresponding author upon reasonable request.