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Evaluation of stigma among patients reporting to a tertiary care psychiatric center

 Department of Psychiatry, Dr D.Y. Patil Medical College, Dr D Y Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission26-Nov-2021
Date of Decision21-Dec-2021
Date of Acceptance30-Dec-2021

Correspondence Address:
Suprakash Chaudhury,
Department of Psychiatry, Dr D.Y. Patil Medical College, Dr D Y PatilVidyapeeth, Pimpri, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_920_21


Background: Stigma toward mental illness is a pervasive concern that impacts the way psychiatric disorders are perceived. Aim: This study was aimed to evaluate the stigma experienced by patients visiting a psychiatric care facility and the associated factors contributing to the development of stigma. Methodology: 150 patients presenting to Psychiatry outpatient department of a tertiary care centre were screened using Mini international neuropsychiatric interview questionnaire to segregate patients into various psychiatric groups. These patients were further assessed for the degree of stigma utilizing the Stigma scale and Internalized Stigma of Mental Illness-10. Results: 60.7% of the participants reported facing discrimination, which was highest in those with mania. 67.3% patients preferred not to disclose their illness, especially those with psychotic disorders. Eighty-six percent did not expect any positive results from their illness, most of them with psychotic disorders. 68.7% of the patients experienced total stigma, highest in mania. Sixty-four percent experienced high internalized stigma mostly in mania. Stigma was irrespective of age, sex, education, employment, and family type. Conclusion: A large segment of participants in the study sample claimed to have suffered from stigma, i.e., they faced discrimination, preferred not to reveal information about their illness, denied any positive outcomes from their illness, and endured self-stigma owing to their illness. Patients with mania faced the most discrimination, total stigma, and internalized stigma whereas disclosure and positive aspects were mostly in psychotic disorders. High levels of stigma observed are a barrier to availing mental health-care facilities.

Keywords: Internalized stigma, mania, mental illness, psychosis, stigma

How to cite this URL:
Davis S, Gupta N, Samudra M, Dhamija S, Chaudhury S, Saldanha D. Evaluation of stigma among patients reporting to a tertiary care psychiatric center. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=339737

  Introduction Top

12.2%–48.6% of adults suffer from psychiatric illnesses in their lifespan. India has a burden of 2%–5% of major psychiatric illnesses and 10% suffer from minor mental disorders. Approximately 20% of psychiatric disorders in our country require mediation by a psychiatrist.[1] More than 70% of people with mental illness worldwide receive no treatment leading to a mental health gap. Research suggests that a major cause for avoidance of treatment is stigma.[2]

The prevalence of mental disorders in India is estimated to be 5.82%–7.35% accounting for around 70 million people.[3] In addition, only 0.2 psychiatrists per 100,000 persons are available in our country compared to the global figures of 1.2.[4] Also, developing countries are deep rooted in cultural beliefs and traditions which may prove as a hindrance to accessing mental health care in addition to stigmatization.

“Stigma” is defined as a set of negative or unfair beliefs held by a group of people or the society at large. Stigma related to psychiatry saw an increased interest after Goffman's publication of Stigma– Notes on the Management of Spoiled Identity[5] which has evolved into a multifaceted concept ever since. He postulated stigma to be a hallmark that is disgraceful socially which causes people to be unfairly denounced. Link and Phelan described it excellently in four components: i.e., (a) It is basically a tag of an outsider; (b) the tag usually has a negative connotation; (c) it leads to a divide between “them” and “us;” and (d) this separation leads to a loss of standing in the society along with prejudice.[6] It leads to association of mental illness with unpredictability, loss of character and inability to care for self which in turn causes a reduction in the quality of life.[3]

Research on mental illness stigma has been done extensively in India and abroad.[3],[7],[8],[9],[10],[11],[12],[13],[14],[15] These studies suggest that stigma is highly prevalent all across the globe, with patients being labeled and shunned. However, they have used different assessment instruments which makes nonuniform comparisons. The Stigma Scale has been used in a few studies[3],[11],[12] with an Indian study using it to evaluate stigma in the armed forces.[11] Two studies have also validated the Internalized Stigma of Mental Illness (ISMI) Scale in India.[14],[15] Exploring the role of sociodemographic and clinical parameters in perpetuating mental illness stigma, along with how it varies among the various diagnostic groups has not been studied in conjunction. Hence, the present study was conducted to bridge the gap.

  Methodology Top

A cross-sectional survey of patients was carried out in which 150 patients reporting to the Psychiatry outpatient department (OPD) of a tertiary care center in Maharashtra were recruited from July 2019 to July 2021. Institutional Ethics Committee and Scientific Committee Clearance (Ref. no. I. E. S. C./178/2019, Research Protocol no. IESC/PGS/2019/55, dated September 11, 2019) was obtained before the start of the study and the participants were included after obtaining written informed consent. Inclusion criteria specified were 18 years of age and above and those clinically stable to comply with the interview. Patients unwilling to undergo the complete study protocol or those who showed evidence of intellectual disability or organic brain pathology were excluded from the study.

The patients were explained the aim and objectives of the study. Interview-based questionnaire was given by a qualified psychiatrist. Relevant sociodemographic and clinical information was gathered and assessed. Patients were evaluated on the Mini-International Neuropsychiatric Interview (MINI)[16] to screen for various psychiatric manifestations and stigma was evaluated using Stigma scale[17] and ISMI-10 scale.[18] The tools used in the study are as under:

Mini international neuropsychiatric interview

The MINI was designed by mental health professionals and general practitioners in 1990 in the United States and Europe for DSM 3R and ICD 10 psychiatric disorders. It is a brief; structured diagnostic interview that takes approximately 15 min to perform. It is the interview of choice for psychiatric evaluation in most studies. The MINI is split into modules classified on the basis of letters corresponding to various diagnostic categories. The tool consists of 86 psychiatric manifestations and a series of sub-scores is generated on: Depression, mania, anxiety and phobias, obsessive ± compulsive disorder, substance use disorder, psychosis, unspecified disorder (including dementia), and pervasive developmental disorder (autism).[16]

Stigma scale

Multiple efforts have been made to ascertain the notions regarding psychiatric illnesses and the stigma. Most of the research on this topic has focused on the community at large.[10],[11] To overcome this hurdle, Michael King and his colleagues developed a universal scale to quantify stigma of mental illness.[17] This 28-item scale encompassed three factors capturing the multidimensionality of stigma. A 5-point Likert scale was employed for measuring all the questions ranging from 0 (strongly disagree) to 5 (strongly agree).[17]

The first factor, “discrimination,” contained 13 statements focused on malevolence regard by others or lost opportunities because of preconceived/detrimental notions.

The second factor, “disclosure,” involved 10 statements that assess views about revealing information regarding one's mental health.

The third factor, “positive aspects” contained 5 statements that measures individuals' rejection of the potentially positive aspects of experiencing mental illness. Higher scores for all three factors meant greater stigma.

Cronbach's a for the 28 items scale was 0.87. Cronbach's a for the first sub-scale (discrimination) was 0.87; for the second (disclosure) 0.85 and for the third (positive aspects) 0.64. The mean sub-scale scores had higher correlations with the overall stigma score than with each other thus encapsulating the various facets of stigma.[3],[17]

Internalized stigma of mental illness scale-10

The ISMI scale is a 29-item questionnaire which takes about 5 min to complete and includes the following sub-scales: Alienation, Stereotype Endorsement, Stigma Resistance, Discrimination Experience and Social Withdrawal. Answers are coded on a 4-point Likert scale: 1 (strongly disagree) to 4 (strongly agree). It has high internal consistency reliability (Cronbach's a = 0.90) and has been widely used around the world[13],[18],[19],[20] being validated in a variety of languages.[19],[21] Most studies in the past have used the full version of the ISMI scale individually to analyze the various aspects of internalized stigma. Here we have used a 10-item version of the ISMI, takes 1–2 min to complete and contains the two strongest items from each sub-scale of the original 29-item scale.

There are two methods of score interpretation. The 4-category method divides scores into the following categories: 1.00–2.00 (no to minimal internalized stigma), 2.01–2.50 (mild internalized stigma), 2.51–3.00 (moderate internalized stigma), and 3.01–4.00 (severe internalized stigma). The 2-category method takes into account a midpoint and scores are computed as being above or below this point: 1.00–2.50 (low internalized stigma) and 2.51–4.00 (high internalized stigma).

Statistical analysis

Data were compiled on Microsoft Excel and SPSS (IBM, Atlanta, USA) was used for analysis. Descriptive analysis included computation of frequency and percentages for categorical variables and mean and standard deviation for the continuous variables. Frequency data was compared using Chi-square test and Fisher exact test. Ordinal data was compared using Kruskal–Wallis One-Way analysis of variance (ANOVA) test. A P < 0.05 was considered to be statistically significant. Regression analysis was performed using Spearman's correlation coefficient to ascertain predictors of stigma.

  Results Top

The sociodemographic and clinical profile of the participants is shown in [Table 1]. The number of males being double, half of the participants are educated up to middle school (31–40 age group) being employed, married, belonging to a nuclear family, hailing from lower socioeconomic class and an urban background, suffering from psychiatric illness for a duration of 1–5 years. The prevalence of psychiatric disorders is shown in [Table 2], with psychotic disorders being the most common and a male preponderance for substance use disorders. Stigma scores with their sub-scales are shown in [Table 3] with 68.7% reporting high stigmaand 64% reporting high self-stigma.
Table 1: Sociodemographic and clinical variables

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Table 2: Mini international neuropsychiatric interview diagnostic groups

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Table 3: Stigma scale subscores of patients

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Factors associated with the experience of stigma

Among the sociodemographic variables, marital status was negatively correlated with total stigma scores and internalized stigma both of which were lowest in married participants and highest in participants separated or divorced. Socioeconomic background plays a role in perpetuation of stigma with discrimination, positive aspects, total stigma and internalized stigma which were highest in those from lower socioeconomic background and lowest in those belonging to middle socioeconomic background, as majority of our samples (38.7%) belonged to middle socioeconomic strata. Domicile also is implicated in stigma as discrimination, total stigma and internalized stigma were higher in rural population than urban population.

Among the clinical variables, total duration of illness was positively correlated with stigma, i.e., discrimination, total stigma and internalized stigma were highest in 1–5 years duration of illness. Help seeking was assessed under two groups i.e., those visiting a care provider themselves and those being brought to medical attention by family members/relatives. While pursuing care for psychiatric conditions, patients usually explore a multitude of options before visiting a psychiatrist which could be attributed to awareness and level of education. Findings revealed that all the domains of stigma scale (discrimination, disclosure, positive aspects and total stigma) and internalized stigma were lower in those seeking help themselves and higher in those who had taken an elaborate route to a mental health professional rather than visiting them directly.

Comparison of stigma amongst the various disorder groups

Kruskal Wallis One Way ANOVA test was applied to compare amongst the 7 groups which revealed the following findings: Patients with mania and psychotic disorders faced the most discrimination whereas those with anxiety disorders and depression faced the least discrimination. Disclosure was highest in those with psychotic disorders whereas those with anxiety disorders were least likely to be ashamed to disclose their illness. Patients with psychotic disorders did not experience any positive outcome from their illness whereas those with depression reported the most positive results due to their illness. Both total stigma and internalized stigma was highest in Mania and lowest in anxiety disorders [Table 4].
Table 4: Comparison of stigma amongst the various psychiatric disorders using Kruskal-Wallis test

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Predictors of stigma

Help-seeking and marital status significantly predicted total stigma and internalized stigma whereas exhaustion of options before visiting a psychiatrist also additionally predicted total stigma on regression analysis using Spearman's correlation coefficient [Table 5] and [Table 6].
Table 5: Multiple regression analysis for predictors of total stigma scores: Coefficientsa

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Table 6: Multiple regression analysis for predictors of internalized stigma of mental illness scores: Coefficientsa

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  Discussion Top

This study explored the sociodemographic and clinical correlates of stigma of mental illness along with how stigma varies among various disorder groups using a hospital-based sample from Western Maharashtra. Age, gender, education, occupation and family type had no bearing on the stigma as males outnumbered females (2:1), most participants being educated up to middle school and working despite their illness to support their families. Past studies have highlighted that female gender[3],[10],[11], older age, lower education levels, nuclear family setup, and unemployment[22] are associated with significantly higher stigma regarding mental illness.[8],[23] Whereas a few differ citing identical stigma based on age and family type.[11]

Increasing age does not necessarily lead to increasing stigma as younger people in treatment also experienced more stigma related to mental health problems. Level of education could also be a double-edged sword as educated masses might associate psychiatric illness with lower level of mental faculties; and therefore, would be uncomfortable disclosing their illness fearing loss of credibility in the society.[3]

Traditional joint families are the norm in India with the burden of care for psychiatric patients being dispersed. This leads to better prognosis than that of a nuclear family and subsequently lowers stigma.[24] Stigma also poses a major barrier to employment as people with severe and common mental disorders are 7:3 times more likely to be unemployed, respectively, than people with no disorders.[22]

Marital status is the most widely investigated, those married tend to have lesser incidence of psychiatric illnesses[25] due to social and emotional support.[26] A study assessing internalised stigma among people with mental disorders reported poor social relationship-related quality of life and high levels of seclusion.[27] The current study reproduced these findings with stigma being lowest in married and highest in separated participants.

Socioeconomic background and domicile are implicated in awareness of mental illnesses and subsequent stigma towards the same owing to cultural practices. We found stigma to be higher in those from lower socioeconomic background, similar to older studies[28],[29] though a few studies were in disagreement. Higher socioeconomic background was associated with higher levels of stigma.[30],[31] In rural India, prevailing cultural beliefs about mental illness lead to higher associated stigma, similar to our study.[32] A few that exist in India pertain to black magic being performed on the patient or the evil eye being cast on them. Some also believe it to be a punishment from the Gods for their former transgressions. Another factor could be poorer access to mental health services[29] due to the paucity of psychiatrists in the interior locales of India. According to the 2015–2016 National Mental Health Survey, the number of psychiatrists in the country varied from 0.05/100,000 persons in Madhya Pradesh (central India) to 1.2 in southeastern Kerala. Except for Kerala, all other states fell short of the WHO's requirement of at least 1 psychiatrist/100,000 persons.[33]

Psychiatric illnesses are usually long lasting and patients end up suffering for many years due to delay in seeking treatment, drug dropouts, adverse effects of psychiatric medications etc. The total duration of psychiatric illness can play a role in perpetuation of stigma and vice versa. The present study shows higher stigma in those suffering for 1–5 years, whereas it was seen to reduce in the >10 years group. A few contributory factors might be complete recovery/psychoeducation/acceptance of the illness in the long run. A study conducted in Nigeria exploring this aspect noted that stigma was directly proportional to the duration of illness.[34]

Availing help from a psychiatrist is a taboo in society and patients end up suffering for long duration without getting the necessary intervention. Help can be sought be either the patient themselves or the family members depending on the education level, awareness regarding mental illness,[35] nature of the illness, age,[36] availability and proximity of services, etc. In our study, majority were brought to attention by family members or relatives. This signifies either lower levels of awareness or nature of the illness itself wherein there is a loss of insight into the illness. In such situations, patients might not acknowledge their illness or the need to seek help leading the family to intervene.

Often there exists an intricate system adopted by patients in visiting a psychiatrist with them seeking out multiple options for care, i.e., faith healers/Ayurvedic doctors/general practitioners and so on. The nonavailability of mental health services, stigma, destitution, lower literacy and superstitions associated with mental disorders, especially in rural areas, coupled with the unwillingness or inability of families to care for their mentally ill relatives, appear to be the main contributory factors.[37] Stigma is negatively associated with allopathic help seeking while there is a positive association with previous informal help-seeking.[38] Our study echoes these findings and suggests stigma and self-stigma were lower in those seeking help themselves whereas it was higher in respondents having exhausted all options before visiting a psychiatrist.

Psychiatric disorders in accordance with mini international neuropsychiatric interview

Psychotic disorders (46.7%) were the most prevalent in our study. These patients are brought more readily to the hospital as they are considered dangerous or unpredictable. Males had higher prevalence of substance use disorders whereas other disorders did not have a predilection for gender (M: F being 2:1 in our study). Certain mental illnesses are epidemiologically and stereotypically more associated with men (e.g., many externalizing disorders, alcohol dependency), whereas other disorders are more associated with women (e.g., major depression) [Table 2].

Stigma scale

Previous studies have used either parts of this scale or modified versions by Brohan et al.,[39] Flores et al.[40] Lonzg et al.[41] Silverman.[42] Research on stigma has concentrated on major mental illness groups which are, schizophrenia, major depressive disorder, and bipolar disorder. It was found that schizophrenia is more stigmatized than major depression.[43]

On analyzing the subsets of the stigma scale, our study revealed that 60.7% participants reported facing discrimination [Table 3]. Indian studies employing the stigma scale in its entirety showed similar results.[11] Research done in Canada and UK has also reported stigma but have denied been discriminated against by police, employers, the education system, or health care providers. These groups have previously been identified as being particularly stigmatizing, which indicates a positive result that attitudes toward mental illness may be evolving among various groups of people.

Due to lack of awareness of the symptomatology of mental health disorders in India, presentation of mania and psychosis are difficult to differentiate by the layman and are both considered severe forms of mental illness, a danger to others, erratic in their behavior, and to be avoided at all costs. On the other hand, anxiety disorders and depression are not usually seen as a mental illness and are easily dismissed [Table 5]. These are seen as a group of controllable symptoms caused due to lack of self-discipline and will power.[44] Patients suffering from mental illness do not divulge information about their status at their workplace or to friends for fear of ridicule. Disclosure can prevent adverse outcomes. It can lead to work adjustments, social and emotional support. The current study found 67.3% patients feared telling others about their mental illness, similar to studies from UK and Canada.[12] Findings from the INDIGO Group, which has interviewed individuals with mental illness across 27 countries worldwide, reported that 40% of people with schizophrenia felt the need to conceal their diagnosis, whereas 70.8% of people with major depressive disorder concealed their diagnosis.[45] Finding in our study was considerably less.

Apart from the negative impact of mental illness on the lives of patients, some report positive outcome from their illness, namely becoming more understanding and accepting of other people. Studies analyzing this aspect found that most participants did not expect any positive results from their illness.[11] Although, studies in Canada and UK have revealed a more positive outlook, suggesting that people from some regions are better able to acknowledge the positive impact of mental illness has had on their acceptance of others.[12] On analyzing the various diagnostic groups, psychosis was not associated with any positive outcome whereas those with depression reported that they had become stronger due to their illness. There have been no studies in the past assessing the positive aspects of psychiatric illnesses.

Stigma is significant and pervasive towards the mentally ill as has been shown by the total stigma scores [Table 3]. On an average, total mean stigma scale scores were higher for participants in this study (68.2) compared to scores reported by King et al. (62.6)[17] and by other studies conducted abroad (61.0, 60.15).[39],[40]

Among the disorder groups, highest scores were seen in mania and psychotic disorders. The general public finds it difficult to comprehend the nature of illness which in turn affects the severity of stigma. Crisp and colleagues found that 75.7% of respondents (community based) rated patients with schizophrenia as more dangerous than 23% or less of those with other mental disorders, such as severe depression or eating disorders.

Internalised stigma of mental illness-10

A person after being diagnosed with a mental illness negates the positive view of self to negative beliefs. During this process, the stigmatized illness identity becomes dominant resulting in the person losing original identity (e.g., as student, parent, employee).[46] This internalized stigma is detrimental to recovery leading to loss of self-worth, increased misery, reduced self-reliance, and increased anticipated depreciation. In our study, out of 150 participants, 64% had high internalized stigma [Table 4], a percentage that was higher than previous studies.[9],[47] The estimation that roughly one third of the sample showed evidence of elevated internalized stigma agrees with prior studies in different settings.[9],[11]

On comparing the various groups for internalized stigma, findings corroborated those from the stigma scale [Table 5]. Past research has shown similar findings with psychotic samples reported higher mean scores.[9],[48],[49] Moderate or high levels of internalized stigma are also endorsed by more than one-fifth of people with affective disorders.[50] Self-stigma is positively related to greater levels of depressive symptoms[49] and hopelessness[51] as well as lower levels of self-esteem and self-efficacy.[52] Taken together, internalizing stigmatizing beliefs arises when an individual advocates and agrees with negative public stereotyping and discriminatory behavior towards individuals with mental illness and may have direct effects on mental wellness.[47]

The experience of stigma can also be predicted by various variables as was found in our study [Table 5] and [Table 6]. A meta-analysis of 127 studies concluded that fundamental sociodemographic variables including age, gender, and race/ethnicity, predict stigma albeit inconsistently in consumers of mental health care.[20]

Despite there being a vast body of research on the topic of mental illness stigma, attitudes toward the same are yet to undergo a transformation. Awareness and sensitization on the subject using anti-stigma campaigns, media approaches, affirming attitudes towards patients and direct contact, could prove beneficial in mitigation of stigma.


It was a hospital-based study, i.e., those reporting to the Psychiatry OPD, hence the findings could not be generalized to the entire population. It is possible that stigma experiences vary over time and may be affected by other life circumstances. The current study was cross sectional, so variations in experiences over time and the factors associated with those changes could not be examined.

  Conclusion Top

We found a high proportion of participants in the current sample agreed that they have experienced stigma, i.e., faced discrimination because of their mental health challenges, avoid disclosing information about these challenges, reject some of the possible positive aspects of experiencing mental illness and endured self-stigma owing to their illness. Patients with mania faced the most discrimination, total stigma and internalized stigma whereas disclosure and positive aspects were most in psychotic disorders. Anxiety disorders saw the least discrimination, disclosure, total stigma, and internalized stigma whereas those with depression had the most positive outcome from their illness.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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