Making the first-episode the last: Mitigating stigma in severe mental illnesses

Internalised stigma is common among people with severe mental illness, and is associated with a 10-fold increased risk of loneliness, which in turn carries an increased risk for psychiatric hospitalisation. The best strategy for mitigating internalised stigma associated with psychosis is effective intervention to make the first (or current) episode of psychosis the last episode, said expert Joseph McEvoy, Professor of Psychiatry, Medical College of Georgia, Augusta, GA, at a thought-provoking plenary at Psych Congress 2018. Psychosocial and case management strategies are also important to promote social inclusion and connectedness and stigma resistance. 

A lower quality of life and social anxiety correlate with personal stigma

The term “stigma” derives from a visible mark that was often made with a pointed object, Professor McEvoy explained. Its associated “undesirable” status has resulted from its use to describe the branding of prisoners. Stigmatising attitudes held by the general public are primitive, non-evidence-based beliefs.

On average, 65% of patients with schizophrenia spectrum disorders perceive stigma and 49% report alienation (shame) as the most common aspect of self-stigma, said Professor McEvoy. A lower quality of life and social anxiety correlate with personal stigma.1

Internalised stigma is associated with an increased risk of psychiatric hospitalisation

Features of internalised stigma and stigma resistance

Stigmatising attitudes directed towards individuals who have a severe mental illness cause considerable distress for those individuals who “give in” and experience “internalised stigma.” Studies using the Internalised Stigma of Mental Illness (ISMI) scale2 have shown that internalised stigma correlates with depression, low self-esteem, and more severe symptoms.3

Compared with individuals with mental illness who have “stigma resistance” and who do not “give in” to stigmatising attitudes, those who experience internalised stigma are more likely to be lonely4 and have:

  • more severe psychiatric symptoms5
  • a longer duration of illness6
  • an increased risk of psychiatric hospitalisation4

Internalised stigma correlates with depression, low self-esteem, and more severe symptoms

Stigma resistance correlates positively with self-esteem, empowerment, and quality of life, and negatively with stigma measures and depression. Higher stigma resistance is associated with:

  • a social network with a sufficient number of friends
  • being single or married
  • receiving outpatient treatment7

Strategies to mitigate internalised stigma

Effective antipsychotic therapy is the best way to mitigate internalised stigma

A meta-analysis of 26 randomised controlled trials to mitigate stigma associated with mental illness found no evidence that stigma interventions reduce perceived stigma or self-stigma.8 Although many advocate changing stigmatising attitudes held by the general public, such initiatives have been found to have limited efficacy for overcoming internalised stigma for individual patients, explained Professor McEvoy.

The most important strategy to mitigate internalised stigma is to treat patients psychotherapeutically to make their first (or current) episode of psychosis the last episode, he said.

Social inclusion and connectedness promote stigma resistance

Psychosocial and case management strategies that promote social inclusion and connectedness are also necessary to mitigate stigma internalisation and promote stigma resistance. The importance of these interventions has been highlighted by studies that have found:

  • individuals with psychosis desire to have something productive to do and to be close to someone in the community5
  • individuals with severe mental illness who have high levels of internalised stigma were nearly 10 times more likely to be lonely than those without internalised stigma, and those who were most lonely were 2.69 times more likely to be placed in psychiatric hospitals than those who were less lonely4



AU-NOTPR-0016. February 2021

  1. Gerlinger G, et al. World Psychiatry 2013;12(2):155–64.
  2. Ritsher J, et al. Psych Res 2003;121(1):31–49.
  3. Boyd J, et al. Compr Psych 2014;55(1):221–31.
  4. Prince J, et al. J Nerv Ment Dis 2018;206(2):136–41.
  5. Drapalski A, et al. Psychiatr Serv 201;64(3):264–9.
  6. Turner N, et al. Int J Soc Psych 2017;63(3):195–202.
  7. Sibitz I, et al. Schizophr Bull 2011;37(2):316–23.
  8. Griffiths K, et al. World Psych 2014;13(2):161–75.
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