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Self-stigma in schizophrenia: a systematic review and meta-analysis of 37 studies from 25 high- and low-to-middle income countries

Molecular Psychiatry (2023)Cite this article

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Abstract

In schizophrenia, it is currently thought that stigma experience is increased by psychotic and depressive symptomatology, exposure to stigma at the workplace, and that self-stigma levels vary across countries without knowing the factors explaining these variations. The aim of the present meta-analysis was to synthetize the data of observational studies comprehensively exploring multiple self-stigma dimensions and associated factors. A systematic literature search without language or time restrictions was conducted in Medline, Google Scholar, and Web of Science for studies, last 09/2021. Eligible studies that included ≥80% of patients diagnosed with schizophrenia-spectrum disorders and used a validated scale measuring self-stigma dimensions were meta-analysed using random-effects models, followed by subgroup and meta-regression analyses. Study registration: PROSPERO CRD42020185030. Overall, 37 studies (n = 7717) from 25 countries (5 continents) published between 2007 and 2020 were included, with 20 studies conducted in high-income countries. These studies used two scales with total scores ranging 1–4. The mean estimate of perceived stigma was 2.76 [95% confidence interval (CI) = 2.60–2.94], experienced stigma 2.29 [95% CI = 2.18, 2.41], alienation 2.40 [95% CI = 2.29, 2.52], stereotype endorsement 2.14 [95% CI = 2.03, 2.27], social withdrawal 2.28 [95% CI = 2.17, 2.39] and stigma resistance 2.53 [95% CI = 2.43, 2.63]). Self-stigma levels did not reduce over time. Living outside urban areas, low-income, singleness, unemployment, high antipsychotic dose and low functioning were associated with different stigma dimensions. Some stigma dimensions were lower in studies carried out in Europe compared to other regions. Most studies published since 2007 report that self-stigma is a particular concern for a specific subgroup of patients. This subgroup is characterized by unemployment, high antipsychotic dose and low functioning. We identified important other missing factors that should be explored to improve the effectiveness of public policies and personalized interventions to reduce self-stigma. Importantly, classical illness severity indices (psychotic severity, age at illness onset, illness duration) and sociodemographic variables (age, sex and education) were not associated with self-stigma, moderating previous findings.

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Fig. 1: PRISMA flow chart.
Fig. 2: Forest plot of studies exploring stigma dimensions (experienced stigma, alienation, stereotype endorsement, social withdrawal, and stigma resistance) in schizophrenia.

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Acknowledgements

We thank the following authors for answering our inquiries about their work: H. Komatsu, T.Feldhaus, R.Lencer, B.Aukst-Margetic, Yli.Wong, Y.Mizuno, H.Uchida, Abp.Staring, M. Van Der Gaag, M. Van Den Berge, H.J. Duivenvoorden, C.L. Mulder, C.Brain, Rc.Kessler, S.Galderisi, C.Hippman, Jc.Austin, P. Yanos, D.Kamarodova, J.Dubreucq, W.Gaebel, Wt. Chieng, E.Abdisa, D.Quinn, S. De Jong, O.Esan, Aa. Hasan, A.Lasalvia, M.Sajatovic, N.Thomas, Fhn.Chio, Wws.Mak, V.Vass, L.Violeau, J.Harangozo, B.Reneses, A.Üçok, Ac.Watson, Yw.Lau.

Funding

This work was funded by the FondaMental Foundation, Assistance Publique – Hôpitaux Marseille (APHM) and Aix-Marseille University (AMU).

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Authors and Affiliations

  1. AP-HM, Aix-Marseille Univ., CEReSS—Health Service Research and Quality of Life Center, Marseille, France

    Guillaume Fond, Martin Vidal, Morgane Joseph, Damien Etchecopar-Etchart & Laurent Boyer

  2. FondaMental Foundation, Creteil, France

    Guillaume Fond, Damien Etchecopar-Etchart & Laurent Boyer

  3. Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany

    Marco Solmi & Christoph U. Correll

  4. Department of Psychiatry, University of Ottawa, Ontario, ON, Canada

    Marco Solmi

  5. Department of Mental Health, The Ottawa Hospital, Ontario, ON, Canada

    Marco Solmi

  6. Ottawa Hospital Research Institute (OHRI) Clinical Epidemiology Program University of Ottawa Ottawa Ontario, School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada

    Marco Solmi

  7. Department of Pediatrics, Kyung Hee University College of Medicine, Seoul, Republic of Korea

    Dong Keon Yon

  8. Center for Digital Health, Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul, Republic of Korea

    Dong Keon Yon

  9. The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA

    Christoph U. Correll

  10. The Zucker Hillside Hospital, Department of Psychiatry, Northwell Health, Glen Oaks, NY, USA

    Christoph U. Correll

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Contributions

Concept and design: LB, GF; Acquisition and analysis: MV, MJ, GF, and LB; Interpretation of data: LB, GF; Drafting of the manuscript: LB, GF; Critical revision of the manuscript for important intellectual content: All the authors; Statistical analysis: LB; Supervision: GF.

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Correspondence to Guillaume Fond.

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Competing interests

CU Correll has been a consultant and/or advisor to or has received honoraria from AbbVie, Acadia, Alkermes, Allergan, Angelini, Aristo, Boehringer-Ingelheim, Cardio Diagnostics, Cerevel, CNX Therapeutics, Compass Pathways, Darnitsa, Gedeon Richter, Hikma, Holmusk, IntraCellular Therapies, Janssen/J&J, Karuna, LB Pharma, Lundbeck, MedAvante-ProPhase, MedInCell, Merck, Mindpax, Mitsubishi Tanabe Pharma, Mylan, Neurocrine, Newron, Noven, Otsuka, Pharmabrain, PPD Biotech, Recordati, Relmada, Reviva, Rovi, Seqirus, SK Life Science, Sunovion, Sun Pharma, Supernus, Takeda, Teva, and Viatris. He provided expert testimony for Janssen and Otsuka. He served on a Data Safety Monitoring Board for Lundbeck, Relmada, Reviva, Rovi, Supernus, and Teva. He has received grant support from Janssen and Takeda. He received royalties from UpToDate and is also a stock option holder of Cardio Diagnostics, Mindpax, LB Pharma and Quantic. Marco Solmi received honoraria/has been a consultant for Angelini, Lundbeck, Otsuka. All other authors declare no competing interests.

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41380_2023_2003_MOESM2_ESM.docx

Supplementary Figure 1. Funnel plots for each stigma dimension (Perceived stigma dimension was not presented because of insufficient number of studies).

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Fond, G., Vidal, M., Joseph, M. et al. Self-stigma in schizophrenia: a systematic review and meta-analysis of 37 studies from 25 high- and low-to-middle income countries. Mol Psychiatry (2023). https://doi.org/10.1038/s41380-023-02003-4

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  • DOI: https://doi.org/10.1038/s41380-023-02003-4

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