The general impact of self-stigma of mental illness on adult patients with depressive disorders: a systematic review

Depression is a mood disorder in which people exhibit constant feelings of sadness, decreased pleasure and a loss of daily functioning [1]. Depression affects about 3.8% of the world’s population [2]. Furthermore, it is the leading cause of suicide [3]. For instance, the United States reported that 40% to 80% of adults who attempted to commit suicide were found to have been diagnosed with depressive disorder [4]. The global rate of depression among adults is estimated to be 10.7% [2]. The mental and psychological changes often appear in adulthood [5]. Consequently, the peak age of onset for mental illnesses occurs at this time [6]. Thus, adult patients with depressive disorders become more susceptible to stigma [7], which increases their risk of experiencing the negative effects of mental illness stigma [8]. Depression is strongly associated with self-stigma. The prevalence of self-stigma among patients with depression revealed a significant rate of 29% [9]. The self-stigma, however, is discussed more with schizophrenic disorder rather than mood disorders such as depression. Patients with schizophrenia suffer more intensely and regularly from self-stigma than patients with other mental illnesses [10]. Additionally, the level of self-stigmatization is altered among psychiatric disorders.

The systematic reviews for etiology and/or risk is utilized for this review. This kind of review is established to determine the relationship between specific exposure or risks and outcomes [21]. Furthermore, this type of review is used to determine the extent and impact between an exposure and a health outcome [22]. The research proposal for this review has been registered to Prospero (ID number: CRD42022366555). However, there is adjustment on the current review, that made it differ from the registered protocol. Researchers should consider modifying and expanding inclusion and exclusion criteria and minor changes to the research question after a deep understanding of the research topic [23]. This modification concerned the research question which has been slightly modified to become as follows: ‘the general impact of self-stigma on adult patients with depressive disorders’ instead of ‘the experience and impact of stigma in adult patients with depressive disorders’. The purpose for this change is to keep the research question focused on the impact only rather than experiences and to narrow the research question by specifying the type of stigma.

The traditional ‘PICO’ framework for systematic reviews of effectiveness does not align, however, with questions relating to risk and etiology [21]. A systematic review of etiology and risk should follow the ‘PEO’ framework, which indicates Population, Exposure of interest (independent variable) and Outcome (dependent variable) [21, 22]. The research question for this review is as follows: ‘What is the general impact of self-stigma on adult patients with depressive disorders’. Thus, the ‘PEO’ question framework is appropriately used as follow; P, Adult patients with depression disorders, E, Self-stigma of mental illness and O, General impact on the patients’ lives. The population category in this review is clearly stated as adult patients ages eighteen years and above who have been clinically diagnosed with one of the depressive disorders. The exposure is an independent variable, which is the patients’ exposure to self-stigma. The outcome of the present study is the general impact of self-stigma on adult patients with depression. The term ‘general impact’ includes many aspects in which self-stigma could affect patients’ lives, such as the quality of life and cognitive ability. The inclusion and exclusion criteria of the primary included studies are illustrated in Table 1.

The search procedure initially started in February 2022 and ended in June 2022. The databases utilised were limited to: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database (EMBASE) and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The published and unpublished research that fulfilled the research criteria and that was related to the review topic was reviewed. The search included scanning the research results’ titles, abstracts. The suggested search strategy of the ‘three-phase process’ by the JBI was adopted for this review. First, an initial search was conducted in MEDLINE to identify all the possible keywords associated with the current research topic. Second, the previous step to all the included databases was applied with caution toward each specific database’s characteristic of searching methods. Third, the references list of the collected studies was scanned to find additional studies to prepare for the appraisal step. The authors of the current study examined the titles and abstracts of the search results and excluded research that obviously did not meet the inclusion criteria for this review. Full-text articles were retrieved and carefully inspected to ensure they contained the inclusion criteria. The methodological quality tool used to assess the primary studies for this review is the JBI critical appraisal checklist for analytical cross-sectional studies. Two independent reviewers appraised the quality of the selected studies. The JBI checklist was modified by removing two questions related to the confounding factors, since the included studies have not reported the presence of confounding. The studies were critically appraised based on the following criteria:

In this review, some of the included studies are dissimilar regarding participants and methods of assessing the exposure, which makes it inappropriate for the author to apply meta-analysis approach. Therefore, A textual narrative synthesis approach was utilised for this review. This approach aimed to collect the data based on categories derived from the studies’ findings [25]. This approach was selected intentionally as the research area has not been investigated before through a systematic review. Furthermore, narrative synthesis assists in searching systematically and classifying the data for the first time [26]. Moreover, according to the JBI framework the textual combination of data is recommended when the included studies are diverse in terms of population, methods, or findings [25]. Furthermore, any clarification or missing data regarding the included studies was resolved by contacting the authors. For instance, the authors of one of the included studies (Hasan and Musleh, 2018) [27] were contacted to seek clarification about the tool they used to assess self-stigma, because this will assist the authors of this review to properly evaluating and critiquing the paper. Lastly, the steps of this review have been reported through PRISMA 2020 checklists for abstract and main text.

The search process resulted in the identification of 302 studies. The titles and abstracts were scanned for the total identified studies. Thirty-six studies appeared suitable for this review; however, after comparing them with the inclusion criteria for the current review, eight studies were included and twenty-eight were excluded for not fulfilling the inclusion criteria. The search process was done with the library team’s assistance at the University of Nottingham. The research characteristics of the included studies are illustrated in Table 2. The sequence of the search results’ process is illustrated through PRISMA 2020 flow diagram in Fig. 1.

The results of this review showed that there is a significant impact of depression self-stigma on QoL with a variant impact on the aspects of social relations, school, and study. Low self-esteem was reported as an impact of depression self-stigma; however, a single study indicates that low self-esteem is a symptom of depression, which could be due to depression itself or self-stigma. Self-blame and worthlessness were shown as an effect of self-stigma as the patients reported that they prevented themselves from taking an action in at least one life domain due to their mental illness condition. Concerning the comparison of self-stigma levels among patients with mental illness, most studies showed that schizophrenia was higher in experiencing self-stigma of MIS. A summary of the results was represented in Table 3.

All the included studies assessed and addressed the impact of self-stigma on adult patients with depression. The impact was found to lower three aspects of the participants’ life and personality: QoL, self-worthiness and self-esteem. The QoL and self-worthiness were negatively influenced by the self-stigma of depression. Self-esteem varied slightly; some studies claimed that self- stigma led to low self-esteem, and a single study stated that depression in isolation could lead to lower self-esteem without self-stigma. Regarding the self-stigma comparison, most of the included studies found that schizophrenia patients showed higher levels of self-stigmatization. However, an individual study indicated that patients with BPD have higher levels of self-stigma, followed by schizophrenia, then, depression. Nevertheless, depressive disorder reported higher levels of patients’ self-blame and stigma resistance. A previous study found that self-stigma was associated with low QoL among patients with depressive disorders [37]. In general, internalized stigma led to lower QoL regardless of the type of mental illness. Further, the fact of being a person who sought psychiatric help could develop a negative self-image. As deduced from this review, the hospitalized patients reported higher levels of internalized stigma, which accordingly exposed them to the consequences of self-stigma, such as poor QoL [29]. In regard to social life, this review explored patients’ challenges while attempting to establish a social relationship. A study examined the impact of social interaction (SI) on 104 adult patients with severe mental illnesses [38]. This study found that negative SI significantly led to lower QoL, while supportive SI was related to higher QoL [38]. Further, they found that perceived stigma fairly liaised between negative SI and poor QoL [38]. The difference between negative and supportive SI on the patients’ QoL justifies why this review reported variant results about the impact of SSD on social life. Perhaps some participants received supportive SI and public acceptance, unlike others. Moreover, patients who received negative SI might prevent themselves from social interaction or building social relationships since they predict discrimination based on a previous experience. Anticipating discrimination is reported in this review as a behaviour observed by patients with depression who are identified to have SSD. This behaviour will encourage patients to hide their mental illness to prevent discrimination. Concealing mental illness by psychiatric patients is often appears with self-stigma of mental illness and it is the opposite of ‘stigma disclosure’. This review showed that hiding stigma is common in depressive disorders. Patients with depression tend to hide their mental illness due to their feelings of shame and self-stigmatization, which creates challenges and burdens for the patients while they try to cope with their lives and hide their mental disabilities. Hence, the elimination of mental illness stigma could be obtained by revealing the mental illness history of the affected person [18]. In regard to the self-esteem, a study reported high levels of self- esteem in self-stigmatized patients who received peer support [39]. Furthermore, family and peer support played a significant role in reducing self-stigma. The current review showed high levels of self- stigmatization among patients with depression who lived with their unsupportive parents in Asian and Middle Eastern countries. A recent systematic review aimed to investigate the frequency of mental illness self-stigma in different cultural and geographic areas [40]. The study found that the highest frequency was in South-East Asia (39.7%) and the Middle East (39%). Mental health problems are often neglected and hidden in Asian culture because admitting mental illness is usually associated with shame, stigmatization and lack of family support [41]. Furthermore, McGuire and Pace (2018) studied the impact of self-stigma of depression between Christians and non-Christian participants diagnosed with depression [42]. The study showed an increased level of self-stigma in the Christian group, which reveals that religious and cultural beliefs impacted the self- stigma of depression. Regarding self-worth, Corrigan, Larson and Rusch (2009) identified the “Why Try” effect of self-stigma [43]. This effect occurred when people with psychiatric disorders considered themselves unworthy or unqualified to achieve life goals due to their application of public mental illness stereotypes to themselves [44]. Corrigan et al. (2009) [43] showed that negative self-worth was observed highly in patients with depression and linked with offensive stereotypes to themselves [34]. An example of the patient’s thought is “someone like me is just not worth to be successful in life” [43]. Correspondingly, the findings of the current review reported reduction in self-worth due to SSD. The forms of self-worthlessness include the patients’ refusal to get a job and to blame themselves for their mental illness. In this review, the level of self-stigma was altered among mental illnesses, but most of the included studies reported a high level of internalized stigma in schizophrenia, except one study reported high level of stigma on BPD, which could be due to the disorder’s symptoms as it is identified by disturbance of self-image, thoughts, and mood. This increased self-stigmatization in schizophrenia could be due to the evident influence of the public stigma on patients with psychotic disorders. Moreover, the public considered psychotic patients more dangerous and aggressive [45]. Moreover, schizophrenia is characterized by hallucinations and delusions, which are obvious symptoms that easily produce public stigma, unlike nonpsychotic [46]. Therefore, the effect of public stigma will extend to disturbed self-perception, which will result in high levels of internalized stigma. Some published studies, however, reported that nonpsychotic disorders had higher levels of self-stigma compared to psychotic disorders. A tested and confirmed hypothesis indicate that patients with nonpsychotic disorders such as depression were aware of the negative public stereotypes, making them experience self-stigma more intensely than psychotic patients [47]. From the same perspective, in this review self-stigma resistance was reported as high in depression. Also, a study showed that greater stigma resistance was found among patients with depression [48]. Stigma resistance in mental health is defined as the ability to remain unresponsive to mental illness stigma [28]. The resistance was associated with reduced self-stigma, increased self-esteem and improved QoL [49]. The presence of self-stigma resistance among patients with depression could be due to the patients’ awareness of public stigma since patients are aware they will be able to cope with internalised stigma. Some of the included studies, however, reported low stigma resistance, which could be interpreted as a response of depression symptoms such as feelings of worthlessness, anhedonia and irritable mood. Self-blaming is usually linked to depression. A study showed that more than 80% of patients with depression reported self-blaming for failing to achieve life duties such as losing jobs or social relations [50]. Thus, these reasons for self-blaming indicated poor QoL, which is mentioned earlier in this review as an impact of self-stigma. Clearly, self-stigma leads indirectly to self-blaming, and depression demonstrated a higher rate of self-blaming due to internalized stigma. Generalization of the research results is critical when applying the findings to population, settings, and times other than those in the original study. A research evidence can only be applied outside the contexts studied when the settings and population are similar to the original study, otherwise there would be no evidence-based practice [51]. Regarding this study, the culture was an obstacle to generalizing the study findings. The Asian studies in this review reported an impact of self- stigma on self-esteem and self-worth. In contrast, none of the European studies mentioned the effects of self-stigma on self-esteem or self-worth. Consequently, the self-stigma was affected by the culture, traditions and beliefs of the patients’ societies. For example, Asians tend to live with their families, making psychiatric patients more exposed to public stigma by their families, leading to self-esteem disturbance. In addition, three of the included studies in this review have confirmed cultural differences encountered while investigating the impact of self-stigma among patients with depression. Furthermore, A study confirmed cross-cultural differences in the relationship between mental illness self-stigma and other concepts, such as masculine sex norms and negative ideas toward seeking mental help [52]. Consequently, due to cultural differences, the findings of this review could not be globally generalized. Nonetheless, it could be locally generalized based on each cultural type and geographical site.

The current review satisfactorily answered the research question and met the objectives. The review explored the impact of SSD. The impact was demonstrated from the QoL to the profound intrapersonal effect on self-esteem and self-worthiness. The QoL was negatively affected and reflected on negative stereotypes by the patients themselves, which led to poor functioning in life. In addition, due to self- stigmatization, patients with depression tend to hide their mental illness, which is associated indirectly with decreasing the QoL. Moreover, self-stigma has a significantly negative impact on social life.

However, some studies have proven that it insignificantly negatively affects. Furthermore, SSD had a slightly negative effect on academic performance. Intrapersonal impact depicted lower levels of self-esteem and self-worthiness associated with SSD. This study has proven that the lower self-esteem level is hard to decide as an impact of SSD since it is a symptom of depression. Self-worthiness affected the patients by stopping them in at least one life domain. They anticipated discrimination and prevented themselves from taking decisions and getting better opportunities. Moreover, patients with depression reported self-blame for their mental condition. Studying the impact from a global perspective allowed the author to know the majority of the effects of SSD and understand the cultural differences affecting it. The Asian and Middle Eastern cultures showed increasing rates and severity of self-stigma of depression. This study emphasized that public and perceived stigma are associated with the formation of self-stigma. Further, the published studies in this area were heterogeneous regarding the self-stigma scales used, so generating systematic reviews and meta-analysis is recommended based on a unified self-stigma scale used in all of the included studies since this will provide accurate and reliable findings.

The research recommendations and clinical implications of this review were summarized and presented in Figs. 2 and 3.