Self-Stigma, insight and influencing factors among Iranian neurotic psychiatric outpatients

doi:10.21203/rs.3.rs-4191459/v1

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Self-Stigma, insight and influencing factors among Iranian neurotic psychiatric outpatients

https://doi.org/10.21203/rs.3.rs-4191459/v1

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Introduction:

Self-stigma towards neurotic disorders is one the main barriers in help seeking and treatment behaviors and hugely impacts the patients’ quality of life. Insight is one of the factors affecting the internalized stigma. Therefore, the aim of this study is to find the relationship between self-stigma and insight among neurotic patients.

Methods

Participants were diagnosed with one of the neurotic disorders, consisted of Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD) or Obsessive-Compulsive Disorder (OCD) and didn’t have any recurrent episodes during the past six months, who came to outpatient clinics of Tehran Psychiatry Institute and Brain and Cognition Clinic, Tehran, Iran from July 2021 to June 2022. Self-stigma was measured by Mental Illness Stigma Scale questionnaire which is consisted of 34 questions and higher scores indicating higher stigma. Insight was measured by three agree/disagree questions about considering themselves mentally ill, having the need to be visited by a psychiatrist and having the need to use psychiatric medication.

Results

In total, 140 patients entered the study. Eighty-nine participants (63.6%) considered themselves mentally ill, one hundred twenty-six (90%) needed to be visited by a psychiatrist and one hundred and thirteen (80.7%) needed to use psychiatric medication. The mean score of stigma was 64.5 ± 21.0. Patients who needed to be visited by a psychiatrist and use psychiatric medication had higher stigma scores compared to the ones who didn’t (p = 0.002 and 0.003, respectively). Also, more men compared to women considered themselves mentally healthy (p = 0.031) and more women felt they need to consume psychiatric medication (p = 0.041)

Conclusion

Patients who need to be visited by a psychiatrist and consume medications have higher stigma scores compared to the ones who didn’t feel the need for psychiatrist visit or medication consumption. On the other hand, there are no significant differences between the total stigma score of patients among the patients who are aware of presence of their illness and the ones who are not.

insight

neurotic patients

Psychiatry

Social stigma

Mental Health

Stigma is not a personal issue or part of the illness; in general, stigma is a state of separation manifested in society’s negative attitudes towards people who have distinctive features from the main body of the society (1); this attitude is present towards patients with different disorders and in particular, mental health disorders (2,3). Different groups of people, including healthcare providers, share this negative attitude (4,5).

Around 970 million people are suffering from mental health disorders throughout the world (6); meanwhile the prevalence of psychiatric disorders in Iran is 23.6% and are more prevalent among women as their prevalence is 26.5% compared to 20.8% among men (7). As mental health disorders interfere with people’s personal and social lives, they must be addressed properly(8). Neurotic disorders are among the most prevalent and important mental health problems, and define as disorders without psychotic features (9). An effective way to tackle neurotic disorders and their consequences on the lives of the people who are suffering, is through providing mental health support (10); however, stigma is a barrier for the uptake of these services and people with neurotic disorders mention social and self-stigma as a barrier that hinders their help-seeking behavior (11).

There are different types of stigma which drive from groups who interact with the patients; they include public stigma, family stigma, employment stigma and self-stigma (12,13). Self-stigma is one aspect of stigma which describes the personalized negative feelings and beliefs of the patients toward themselves (14). Self-stigma weakens feelings of self-worth, and as a result, person feels less capable of achieving goals; thus, the harms of self-stigma manifest through an internal process and ultimately grow as poor health outcome, treatment seeking and life satisfaction (15,16).

One of the factors which affects stigma is insight towards the neurotic disorder; it is often described as “insight paradox”, considering both its positive and negative effects (17); on one hand it leads to increased adherence to treatment and social presence, on the other hand it could lead to decreased self-esteem, quality of life or even suicide (18,19). Also, patients with different disorders have various levels of insight, affecting the course of their disease (20,21).

As self-stigma and insight both effect the mental well-being of a neurotic patient, finding their relations can benefit patients and societies; in addition, cultural norms and beliefs have a substantial effect on both of them and distinct studies should be conducted in different societies. Despite the importance of this relation, few studies are carried out to find this relation and they have reported divergent findings; it was indicated that insight could lead to higher self-stigma (22) or there weren’t any significant relationship between them (23). Also, related studies are very scarce in Iran, taking the Iranian culture into account. Considering the insufficient knowledge regarding the relation between stigma and insight, we aim to find the relationship between the different aspects of perceived stigma and insight levels among patients with neurotic disorders.

Study Design and Participants

This study was carried out based on cross-sectional design. All the patients with neurotic disorders who received treatment at outpatient clinics of Tehran Psychiatry Institute and Brain and Cognition Clinic, Tehran, Iran, from July 2021 to June 2022, after giving the informed consent, entered the study. Inclusion criteria were: 1) be older than 18 years, 2) be diagnosed with one of the neurotic disorders, including Major Depressive Disorder (MDD), Generalized Anxiety Disorder (GAD) or Obsessive-Compulsive Disorder (OCD), 3) giving informed consent to enter the study and 4) not having any recurrent episodes of disease during the past six months.

The exclusion criteria were: 1) having other somatic diseases that cause stigma, such as tuberculosis, AIDS, vitiligo and parasitic infections, 2) history of diagnosis of other major psychiatric disorders such as schizophrenia, schizoaffective disorder, substance use disorder or bipolar disorder.

Procedures

The patients were diagnosed with either MDD, GAD, or OCD by psychiatrists according to DSM-5 criteria; they didn’t have any recurrent episodes of disease during the past six months based on recorded documents by psychiatrists and self-reported psychiatric history.

Questionnaires

Three Questionnaires were used to obtain the data from participants. 1) using a researcher designed questionnaire, sociodemographic characteristics such as sex, age, marital status, level of education, residence status, having children, condition of employment, economic condition, familial history of psychiatric disorders, history of psychotherapy sessions, years passed since diagnosis and number of annual visits to psychiatrist was collected.

2) The questionnaire of insight towards mood disorders is an eight-question questionnaire, translated into Persian in 2012, and its reliability and validity were verified; the Cronbach's alpha coefficient for this questionnaire was 0.8 (24); each question is consisted of three choices: agree, unsure and disagree. Since this questionnaire was designed specifically for mood disorders, three general questions, were used; insight regarding the presence of mental illness, the need to visit a psychiatrist and the need to use psychiatric medications; each consisted of two choices: agree and disagree.

3) The Mental Illness Stigma Scale questionnaire was translated into Persian by Karshaki and colleagues. This questionnaire helps researcher better understand the extent of stigma caused by neurological and mental illnesses among patients. The translated questionnaire was valid, and Cronbach's alpha coefficient equals to 0.82, indicated good internal consistency. It is consisted of 34 questions, rated from 1 to 5 (strongly disagree or strongly agree); among them, four questions (4, 23, 25, 27) have inverse scores; higher scores showed higher levels of stigma (25).

Data analysis

Descriptive (frequency and percentage) and quantitative (mean and standard deviation) methods were used to present socio-demographic data and the final score of questionnaires. Due to the normal distribution of continues variables (Shapiro-Wilk test, p > .05 and histograms), independent sample t-test and ANOVA were used to compare the means of each group; Pearson’s chi-square was used to assess the differences between groups. Pearson’s correlation was used to find the relation between continuous variables. Level of significancy was p < 0.05. All the statistical analysis was carried out using SPSS version 26.0.

Demographic features

A total of 140 participants entered the study. Ninety-one participants were female (65%), and 49 were male (35%), with a mean age of 40.2 ± 12.1 years. Most participants were married (60%), followed by single (35%) and divorced individuals. Eighty had university degrees (57.1%), and seventy-three were employed (52.1%). Nearly half of the patients (46.4%) have attended psychotherapy sessions; however, more patients had a family history of psychiatric disorders compared to the ones who didn’t (64.3% compared to 35.7%). Detailed demographic characteristics of participants are presented in Table 1.

Insight and stigma score

For the first question of the insight questionnaire, which was about the insight regarding the presence of mental illness, eighty-nine participants agreed (63.6%), and 51 disagreed. Question two was about the need to visit a psychiatrist; one hundred twenty-six participants agreed, and 14 disagreed. Question three was about the need to use psychiatric medications; one hundred and thirteen agreed; in contrast, 27 disagreed (Fig. 1). Regarding the stigma questionnaire, the mean score of stigma was 64.5 ± 21.0.

There was no significant difference in the stigma score between the patients who considered themselves mentally ill or healthy (p = 0.146); however, patients who needed to be visited by a psychiatrist or consume psychiatric medications had higher stigma scores compared to the ones who didn’t (p = 0.002 and 0.003 respectively).

Demographic factors and the differences they make in questionnaire scores were also assessed. By comparing the mean of stigma score and insight questions, the only significant differences between the subgroups were for sex and two of insight questions; more men considered themselves mentally healthy compared to the women (p = 0.031), and more women mentioned that they need to consume psychiatric medication (p = 0.041) (Table 2). Also there was no significant relationship between the stigma score and any of the continues demographic variables; there was no significant difference between age, number of children, years since the start of disease, number of psychiatry visits and any of the insight questions (Table 3).

* Q1: I’m mentally healthy, Q2: I need to be visited by a psychiatrist, Q3: I need to take psychiatric medications.

Table 1

Demographic Characteristics of Participants.
Variable			Number	Percent	Mean (± SD)
Sex	Male		49	35
Sex	Female		91	65
Type of disorder	Major Depressive Disorder		54	38.6
	Generalized Anxiety Disorder		28	20
	Obsessive-Compulsive Disorder		58	41.4
Age					40.2(± 12.1)
Marital status		Single	49	35
		Married	84	60
		Divorced	7	5
Education		Less than diploma	20	14.3
		Diploma	40	28.6
		University	80	57.1
Residence		Owned	89	63.6
Residence		Rental	51	36.4
Have children		Yes	63	45
Have children		No	77	55
Number of Children					1.1(± 1.4)
Employment		Employed	73	52.1
		Housewife	52	37.1
		Student	9	6.4
		Retired	6	4.3
Family History of Psychiatric Disorder		Yes	50	35.7
Family History of Psychiatric Disorder		No	90	64.3
History of Psychotherapy		Yes	65	46.4
History of Psychotherapy		No	75	53.6
Years Since Diagnosis					6.5(± 6.4)
Number of Psychiatrist Visit per Year					4(± 2.2)

Table 2

Comparing the mean score of stigma and insight questions between qualitative variables
Variable		Mean (SD) of Stigma Score	Being mentally healthy		need to visit a psychiatrist		need to use psychiatric medications
Variable		Mean (SD) of Stigma Score	Yes	No	Yes	No	Yes	No
Sex	Female	66.7 (21.0)	52	39	83	8	78	35
	Male	60.5 (20.6)	37	12	43	6	35	14
	P-value*	0.095	0.031†		0.561		0.041†
Type of disorder	Major Depressive Disorder	65.2 (20.4)	36	18	49	5	43	11
	Generalized Anxiety Disorder	67.7 (21.4)	17	11	24	4	24	4
	Obsessive-Compulsive Disorder	62.3 (21.5)	36	22	53	5	46	12
	p-value**	0.512	0.828		0.695		0.754
Marital status	Single	60.6 (20.3)	31	18	43	6	37	12
	Married	67.5 (20.4)	52	32	76	8	72	12
	Divorced	56.4 (28.4)	6	1	7	0	4	3
	p-value**	0.111	0.453		0.585		0.095
Education	Less than diploma	56.6 (23.0)	13	7	17	3	14	6
	Diploma	65.2 (22.4)	26	14	36	4	32	8
	University	66.2 (19.5)	50	30	73	7	67	13
	p-value**	0.183	0.955		0.707		0.375
Residence	Owned	63.6 (20.6)	60	29	79	10	70	19
	Rental	66.2 (21.7)	29	22	47	4	43	8
	p-value*	0.482	0.212		0.520		0.414
Have children	No	62.7 (20.3)	51	26	68	9	64	13
	Yes	66.7 (21.8)	38	25	58	5	49	14
	p-value*	0.274	0.469		0.462		0.426
Employment	Employed	64.5 (18.4)	48	25	66	7	59	14
	Housewife	66.5 (23.6)	30	22	47	5	42	10
	Student	63.6 (14.8)	7	2	8	1	7	2
	Retired	49.0 (31.6)	4	2	5	1	5	1
	p-value**	0.292	0.629		0.954		0.994
Family History of Psychiatric Disorder	Yes	62.2 (23.8)	30	20	45	5	41	9
	No	65.8 (19.2)	59	31	81	9	72	18
	p-value*	0.333	0.513		0.607		0.774
History of Psychotherapy	Yes	64.0 (20.2)	41	24	56	9	54	11
	No	65.0 (21.8)	48	27	70	5	59	16
	p-value*	0.790	0.910		0.158		0.509
p-values of between group comparisons for stigma score was calculated based on: independent samples t-test, * one-way ANOVA

p-values of between group comparisons for insight questions was calculated based on Pearson chi-square

† p-value < 0.05

Table 3

p-values of comparing the mean score of stigma and insight questions between continues demographic variables.
variable	Age Pearson’s R / Mean Difference † (p-value)	Number of children Pearson’s R / Mean Difference (p-value)	Years Since Diagnosis Pearson’s R / Mean Difference (p-value)	Number of Psychiatrist Visits per Year Pearson’s R / Mean Difference (p-value)	Stigma Pearson’s R / Mean Difference (p-value)
Stigma score*	0.042 (0. 618)	0.106 (0.213)	0.097 (0.253)	-0.043 (0.617)	---
Being mentally healthy **	0.28 (0.892)	-0.19 (0.446)	-0.75 (0.506)	-0.17 (0.648)	-5.38 (0.146)
need to visit a psychiatrist**	0.98 (0.774)	0.12 (0.751)	-3.55 (0.169)	0.28 (0.650)	17.84 (0.002)
need to use psychiatric medications**	1.31 (0.616)	0.32 (0.285)	-1.34 (0.419)	0.09 (0.836)	13.40 (0.003)

* Based on Pearson’s correlation

** Based on independent samples t-test

† Mean difference is calculated as the number of people who answered yes minus the number of people who answered no

Stigma and insight regarding neurotic disorders may somehow establish how and even whether people seek help for their mental health problems and impacts the burden of the disease. According to the findings of this study, the stigma score was higher in patients who needed psychiatric visits and consuming medications; also, men considered themselves to be more mentally healthy, and women felt they needed medications more.

The purpose of this study is to determine the relationship between insight and internalized stigma of patients with mental illness and their outcomes in patients’ lives. The insight segment consisted of three inquiries: insight regarding the presence of mental illness, the need to visit a psychiatrist, and the need to use psychiatric medications.

It was demonstrated that patients who need to be visited by a psychiatrist and consume medications had significant higher levels of stigma. This finding is consistent with previous studies who underlined higher self-stigma among those who adhere to professional visits and medication (26,27). Therefore, it is crucial to integrate adherence to treatment practices in anti-stigma programs. On the other hand, patients who adhere to their treatment should be followed up for their self-stigma; as the relationship between self-stigma and illness is crucially essential for a compliant lifestyle and a long-lasting commitment to medication and psychiatric visits (28).

Our findings indicate that there is no significant difference between the total stigma score of patients who consider themselves mentally ill and the others who don’t. This finding is somehow controversial to previous studies; for example, a study conducted in India showed that as patients develop insight into their illness, their levels of stigma escalate. Another study in Hungary indicated that insight, would lead to higher internalized stigma and embarrassment. Nonetheless, this is a two-sided relationship, and as the level of stigma increases, patients have developed more insight over their illness (22,29). However, we should note that the mentioned studies assessed different types of disorders, not only neurotic ones, which could lead to other associations.

When examining patients' different socio-economic demographic features and the effect on their perceived stigma and insight, women more often considered themselves not mentally healthy and required psychiatric medications. One explanation could be the previous fundamental model that the inhibitory effect of masculinity will inhibit patients' willingness to seek help and medication usage (30); thus, Women are more likely to be prescribed and consume psychiatric medications. Our findings are consistent with this statistic (31).

The female gender as a whole has biophysical differences than men; as a result internalized stigma and insight among men and women vary in different aspects (32). These differences could also be perceived from our study, as we can see that women are less likely to feel mentally healthy and need to use more medication.

Another interesting observation is that no difference was observed between the educational groups in stigma score and insight. Our findings oppose some other studies where different relations are reported (33,34), some studies indicated that higher levels of education would reduce stigma, and academically educated patients are likely to have better medication and treatment adherence (35,36); this could be explained by the high number of participants in our sample with university degree and low number who haven’t had diploma; a higher and more balanced data could further investigate this factor.

In our study, age had no significant relationship between total insight and stigma score; this is a debatable finding. One study conducted in 2005 among Taiwanese patients has showed similar results (37). But another theory indicates that as people get older, due to their wide range of experience, they will better accept people's differences and uniqueness (38). Previous studies in the Czech Republic, United States, and Canada have also shown that as patients become old, they have better medication adherence and are more willing to seek help and counseling (26,28,39). As the studies with different findings are conducted in Western countries with western cultures, and the one with similar results is conducted in Asia, we can conclude that among eastern cultures, this relation is less prominent.

Limitations and Implications for Further Studies

There have been some limitations to our study. First, the nature of our study which is a cross-sectional data gathering as well as a small sample size. We would recommend using different study designs as well as a greater sample size which can carry out more precise results, especially for patients with a different spectrum of disorders. Meanwhile, our study showed that stigma has a significant relationship with the need to consume medication, hence we recommend two strategies for this worrisome matter; First a follow-up program in a timely and orderly manner for patients with higher levels of stigma that will lead to better medication adherence; second, an anti-stigma program that can simultaneously focus on help-seeking and better attitudes toward mental illness (5). Lastly, with the matter still being a public health issue we highly recommend early identification of high-risk patients such as the ones with higher levels of internalized stigma and negative attitudes towards their mental illnesses which can lead to prompt management and better quality of life (40).

To conclude, our study concerns stigma and insight of neurotic disorders, showed that the patients who feel the need to be visited by a psychiatrist and consume psychiatric medications have higher levels of perceived and internalized stigma. However, there are no significant associations between the total stigma score of patients and the insight towards the presence of their illness. Another noteworthy finding is that women have higher levels of awareness of their mental illness; they also have better compliance with their medication.

Ethics approval and consent to participate

Before the subjects entered the study, we gave them information about the questionnaires, data privacy, voluntary nature and benefits of participation; they were free to accept or retract their data, and it didn’t have any effect on their treatment process; finally, written consent was obtained from all of the participants. This study was conducted according to the declaration of Helsinki and subsequent revisions and approved by the Ethics Committee of the Iran University of Medical Sciences with the code IR.IUMS.FMD.REC.1399.885.

Consent for publication

Not applicable

Competing interests

The authors have no conflicts of interest to report.

Author Contributions

Conceptualization and design: Ayda Ayoubi, Mohammadreza Shalbafan and Seyed Vahid Shariat; Data analyses: Ali Amirkafi, and Seyed Vahid Shariat; Data collection: Ayda Ayoubi, and Mohammadreza Shalbafan; Initial draft preparation: Ali Amirkafi and Sana Movahedi; Editing & review: All authors.

Funding

The authors disclose receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Iran University of Medical Sciences (Grant no: 1402-3-99-27304).

Availability of data and materials

The dataset used and analyzed during the current study can be shared by the corresponding author upon reasonable request.

Acknowledgement

This study was Dr. Ayda Ayoubi’s graduate thesis to Medical Doctor Degree.

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No competing interests reported.

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Self-Stigma, insight and influencing factors among Iranian neurotic psychiatric outpatients

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Results

Conclusion

Figures

Introduction

Methods

Study Design and Participants

Procedures

Questionnaires

Data analysis

Results

Demographic features

Insight and stigma score

Discussion

Limitations and Implications for Further Studies

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1