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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 33-39

Stigma and discrimination in patients with schizophrenia and bipolar mood disorder


Department of Psychiatry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, Maharashtra, India

Date of Submission02-Aug-2019
Date of Decision27-Oct-2019
Date of Acceptance01-Nov-2019
Date of Web Publication30-May-2020

Correspondence Address:
Dr. Ganpat K Vankar
Department of Psychiatry, Block E, Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aip.aip_49_19

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  Abstract 


Context: Stigma associated with mental illness is devastating and can be detrimental to recovery. Many people with serious mental illness are challenged with the symptoms and disabilities caused by the disease. In addition, they are challenged by the stereotypes and prejudice that result from misconceptions about mental illness. Aims: The aims were to study and compare stigma and discrimination in patients with schizophrenia and bipolar mood disorder. Settings and Design: This is a cross-sectional study of 100 patients selected by purposive random sampling from the psychiatry outpatient department of a tertiary care hospital. Materials and Methods: Fifty patients suffering from schizophrenia and fifty patients suffering from bipolar affective disorder (BPAD) according to the International Classification of Diseases 10 were interviewed. The Discrimination and Stigma Scale (DISC) 12 was used to assess stigma and discrimination of the patients. The DISC 12 asks participants about the experiences of discrimination in various areas of life including employment; mental health care; and interactions with friends, neighbors, and family. Statistical Analysis Used: Statistical analysis was done by using descriptive and inferential statistics using Chi-square test and Student's unpaired t-test. Results: Overall, patients of both schizophrenia and bipolar disorder suffer from stigma and discrimination of the same magnitude. Unfair treatment was similar in both the disorders, while overcoming stigma, stopping self, and positive treatment were significantly higher for patients suffering from schizophrenia as compared to BPAD. Conclusions: Irrespective of diagnosis, mental illnesses evoke stigma and discrimination which impact the lives of people with schizophrenia.

Keywords: Bipolar disorder, discrimination, India, mental illness, schizophrenia, stigma


How to cite this article:
Kumar KS, Vankar GK, Goyal AD, Sharma AS. Stigma and discrimination in patients with schizophrenia and bipolar mood disorder. Ann Indian Psychiatry 2020;4:33-9

How to cite this URL:
Kumar KS, Vankar GK, Goyal AD, Sharma AS. Stigma and discrimination in patients with schizophrenia and bipolar mood disorder. Ann Indian Psychiatry [serial online] 2020 [cited 2020 Jul 14];4:33-9. Available from: http://www.anip.co.in/text.asp?2020/4/1/33/285504




  Introduction Top


People who have a mental illness often feel stigmatized.[1] Around the world, many people with mental illness are discriminated against, have restricted work opportunities, feel stigmatized at work,[2] and are even denied the basic rights afforded to other members of the society.[3] People with mental illnesses have to face two challenges. One is that they struggle with the symptoms and disabilities that occur due to the disease. On the other hand, they are challenged by the ignorance, the stereotypes, and the prejudice that result from misconceptions about mental diseases. As a result of these, people with mental illness do not get the following opportunities that define a quality life: nice jobs, safe and comfortable housing, good health care and affiliation with a diverse group of people.[4]

The term stigma refers to the problems of knowledge (ignorance), attitudes (prejudice), and behavior (discrimination). It is basically how a person sees you after knowing the fact that you are mentally ill. The reaction that the general population has to people with mental illness is termed as public stigma. Self-stigma is the prejudice which people with mental illness turn against themselves.[5] Discrimination is defined as the action or treatment based on stigma and directed toward the stigmatized. It is basically how a person acts after knowing the fact that you are mentally ill.[6]

The stigma and discrimination associated with schizophrenia were seen to have a prominent effect on the lives of those suffering from the illness. From the patient's aspect, a lack of knowledge, the nature of the illness itself, and symptoms associated with the illness were seen as the main reasons for stigma and discrimination. The common effects of stigma were low self-esteem and discrimination in family and work settings.[7]

Research into understanding the stigma experienced by people with mood disorders is important as the World Health Organization also identifies depression as a major contributor to the global burden of disease due to “its relatively high lifetime prevalence and the significant disability that it causes.”[8] A survey-based study of the general population in five metropolitan cities in India found that participants had overall high levels of perceived stigma; female participants showed higher levels of perceived stigma compared to male counterparts.[9]

A qualitative study of stigma by Dinos et al. suggested that individuals with mood and anxiety disorders may experience stigma differently when compared to individuals with psychotic disorders, highlighting the importance of studying the effects of stigma on individuals with a variety of illnesses.[10]

Several studies have found significant internalized self-stigma in patients with schizophrenia.[11],[12],[13],[14] Higher positive symptoms, young age, being unmarried, and being a woman were associated with higher stigma experience in people with schizophrenia, not only from India but also from several other countries.[13],[14],[15] In a study from Western India, there was difference in stigma experienced as per rural or urban background. Patients from rural background more often reported experiences such as society treats differently, ridiculed by others, receiving offensive comments, hiding from relatives, rejecting attitude of people around, and attribution of supernatural cause as the most common sources of stigma. Social exploitation, not fully accepted in the family, pushed into unacceptable social situation, and sexual harassment were more commonly reported by urban patients.[16] Thornicroft et al. in 2009 conducted a survey of stigma of mental illness in 27 countries and found that negative discrimination was experienced by 47% in making or keeping friends, 43% from family members, 29% in finding a job, 29% in keeping a job, and 27% in intimate or sexual relationships. The positive treatment (positive treatment by others despite having psychiatric disorder or no negative treatment when the psychiatrically ill person expected it) was rare.[17]

Thara and Srinivasan found that in India, marriage, fear of rejection by a neighbor, and the need to hide the fact from others are some of the more stigmatizing aspects.[18]

Two studies have compared the stigma experienced by schizophrenia and bipolar disorder. Farrelly et al. found that irrespective of diagnosis, 93% anticipated discrimination and 87% experienced discrimination in at least one area of life in the previous year and also found higher stigma in schizophrenia compared to depression or schizoaffective disorder.[19] Karidi et al. found higher self-stigma in schizophrenia compared to bipolar disorder.[20]

Lognathan and Murthy found gender differences in stigma experienced by patients with schizophrenia. Men reported that their experience of stigma was most acute in their places of employment. Women reported experiences of stigma in relation to marriage, pregnancy, and childbirth.[21] Karambelkar et al. in their study of stigma found that 86% of patients with schizophrenia and bipolar affective disorder (BPAD) experienced stigma. Schizophrenia and BPAD patients did not differ in their experiences of stigma, proving that the tag of mental illness was stigmatizing enough and had no relation with the duration or intensity of illness.[22] Grover et al. conducted a multicentric study to evaluate the stigma and its correlates among patients with severe mental disorders. Seven hundred and seven patients with a diagnosis of schizophrenia and 344 patients with a diagnosis of bipolar disorder currently in clinical remission from 14 centers were assessed on the Internalized Stigma of Mental Illness Scale (ISMIS). Patients with a diagnosis of schizophrenia experienced higher level of alienation, stereotype endorsement, discrimination experience, and total stigma when compared to patients with bipolar disorder overall compared to affective disorder groups; higher proportion of patients with schizophrenia reported stigma in all the domains of ISMIS. In general, stigma is associated with shorter duration of illness, shorter duration of treatment, and younger age of onset. The study emphasized that during the early phase of illness, patients suffered higher level of stigma; hence, stigma interventional programs must focus on patients during the initial phase of illness.[23]

Pal et al. examined the level and impact of internalized stigma in patients with BPAD. Schizophrenia and anxiety disorders were compared on ISMIS and the Stigma Scale. Significant differences were found in all domains of self-stigma measures among the three groups. In patients with BPAD, stigma and its domains were significantly correlated with the measures on monthly income, education, socio-occupational functioning, and quality of life. Patients with BPAD experienced substantial stigma, lower than experienced by patients with schizophrenia and higher than experienced by patients with anxiety disorder (lower). Internalized stigma has a significant impact on self-esteem, socio-occupational participation and functioning, and quality of life in patients with BPAD.[24]

It is thus important to understand how each illness caused stigma and discrimination and then approach it accordingly to mitigate its impact on the lives of the mentally ill and their caregivers.

With this intention, we conducted this study to see and compare the impact of stigma and discrimination in patients suffering from stigma and BPAD.


  Materials and Methods Top


In this cross-sectional study, 100 patients, fifty having schizophrenia and fifty having BPAD diagnosis according to the International Classification of Diseases (ICD) 10[25] were studied. They attended psychiatry outpatient department of a tertiary care hospital. Purposive random sampling was used. Interviews were conducted with patients alone or in the presence of a relative, after taking written informed consent. Prior clearance from the institutional review board was taken before starting the study. Persons between the ages of 18 and 75 years who gave written informed consent and who were in remission since 3 months were included in the study. Patients with mental retardation or any other cognitive impairment and with any other physical or mental comorbidity were excluded from the study.

A semi-structured pro forma for recording sociodemographic data was used. The participants were interviewed using the Discrimination and Stigma Scale (DISC) to assess stigma and discrimination experienced by them.

Discrimination and Stigma Scale 12

The DISC asks participants about the experiences of discrimination in various areas of life including employment; mental health care; and interactions with friends, neighbors, and family. It contains a global scale and four subscales (subscale 1: unfair treatment, subscale 2: stopping self, subscale 3: overcoming stigma, subscale 4: positive treatment).[26]

Analysis

Statistical analysis was done by using descriptive and inferential statistics using Chi-square test and Student's unpaired t-test with SPSS software version 22.0[27] P < 0.05 was considered as a level of significance.


  Results Top


Sociodemographic characteristics of the study participants

Out of the 100 participants including fifty with schizophrenia and fifty with BPAD, it was found that although there was a preponderance of men in both the groups (52% and 64% in schizophrenia and BPAD, respectively), the difference was not statistically significant [Table 1]. Most of the demographic characteristics of both the groups were similar, except that in the BPAD group, patients with shorter disease duration (<10 years) and in schizophrenia group, urban patients were overrepresented.
Table 1: Demographic characteristics of the patients (n=50)

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Stigma score comparison: Schizophrenia versus bipolar affective disorder

The mean score for subscale 1 (unfair treatment) was higher in BPAD, as compared to schizophrenia, but the result was not statistically significant.

For subscale 2 (stop oneself from doing something), subscale 3 (overcoming stigma), and subscale 4 (positive treatment), schizophrenic patients had higher mean scores compared to BPAD patients, and the difference was statistically significant for these three scales [Table 2].
Table 2: Comparison of the scores of subscales and total score of Discrimination and Stigma Scale 12 between schizophrenia and bipolar affective disorder (n=50)

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Discrimination and Stigma Scale subscale scores and demographic characteristics of schizophrenic patients

In the schizophrenic group, the mean scores of subscale 1 (unfair treatment) were higher in single/widowed/divorced/separated compared to the married patients (P = 0.01) and in patients with duration of illness >10 years compared to those with shorter duration of illness (P = 0.01), higher income was associated with higher score subscale 3 with income (P = 0.03) and higher mean scores on subscale 4 (positive treatment with urban residence compared to rural (P = 0.01) [Table 3].
Table 3: Discrimination and Stigma Scale 12 subscale scores and sociodemographic variables in schizophrenia (n=50)

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Discrimination and Stigma Scale subscale scores and demographic characteristics of bipolar affective disorder patients

In the BPAD group, rural residents had a statistically significantly higher score compared to urban patients on subscale 3 (overcoming stigma) (P = 0.009). On the rest of the subscales, the differences were not significant. On the whole, better educated (higher than high school) patients had higher total DISC scores compared to those less educated [Table 4].
Table 4: Discrimination and Stigma Scale 12 subscale scores and sociodemographic variables in bipolar affective disorder (n=50)

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Impact of residence on stigma

In urban patients with schizophrenia, the mean total DISC 12 score was 23.46 (standard deviation [SD]: 9.19) compared to rural patients who had a mean total DISC 12 score of 23.63 (SD: 6.63). The difference was not statistically significant (P = 0.99). For bipolar patients, similar comparison was made and no statistically significant difference was observed between urban and rural patients with regard to mean DISC scores (P = 0.74) [Table 3] and [Table 4].

Impact of duration of illness on stigma

To clarify whether duration of illness impacts the level of stigma for both schizophrenia and bipolar disorder, correlation analysis was run separately for the duration of illness and the DISC scores. For schizophrenic patients, there was a low positive correlation between the duration of illness and the DISC scores (Pearson's correlation r = 0.12, P = 0.40). For bipolar disorder patients, there was a low positive correlation between the duration of illness and the DISC scores (Pearson's correlation r = 0.073, P = 0.61). Thus, duration of illness was not associated with the level of stigma in schizophrenia and BPAD patients.


  Discussion Top


Stigma experienced by patients with schizophrenia and bipolar disorder

The major finding in our study was that patients with schizophrenia and BPAD both suffer stigma and discrimination equally. This is in harmony with earlier studies, which concluded that just a tag of mental illness was sufficient for unfair treatment, and it did not depend on the diagnosis of the patient.[22] Several international and Indian studies have concluded that patients with schizophrenia suffer more stigma compared to those with bipolar disorder.[19],[20],[23],[24]

The total DISC 12 score was slightly higher in schizophrenia group compared to that of bipolar disorder group; however, the difference was not statistically significant. Karambelkar et al. (2016) also concluded that schizophrenia and bipolar disorder patients suffer equal stigma. Both groups of patients with BAPD and schizophrenia showed similar tendencies to hide their illnesses. Rural and urban population (regardless of diagnosis) had equal propensity to hide illness. Agarwal et al. concluded that urban patients more often reported social exploitation, nonacceptance by the family, and sexual.[16]

Discrimination and Stigma Scale 12 subscale score comparisons in schizophrenia and bipolar disorder

The DISC contains a global scale and four subscales (subscale 1: unfair treatment, subscale 2: stopping self, subscale 3: overcoming stigma, and subscale 4: positive treatment). On subscale 1 (unfair treatment), patients from schizophrenia group and bipolar disorder group did not differ significantly. On the rest of the three subscales, patients with schizophrenia exhibited higher scores, which were statistically significant.

Subscale 2 (”stopping self”) scores showed that schizophrenic patients had a greater tendency to stop oneself from doing something as compared to BPAD patients. This can be due to the more continuous nature of the illness in schizophrenia. Shrivastava et al. also suggested that schizophrenic patients delay in psychiatric management because the illness causes “stopping patients from doing things.”[7]

The mean scores on subscale 3 (”overcoming stigma”) were higher in schizophrenia compared to BPAD group.

Similarly, though the mean scores on subscale 4 (positive treatment) were quite low, schizophrenia patients had still higher mean scores compared to BPAD patients. Thus, both schizophrenia and bipolar disorder patients experienced low positive treatment, but that experienced by schizophrenic patients was even lower. This also includes not receiving negative experience when they actually expected untoward behaviors from others.

The total mean DISC 12 score was slightly higher in schizophrenic patients compared to BPAD patients, but the difference was not statistically significant. Thus, broadly, both the severe mental disorders are associated with similar magnitude of stigma.

Sociodemographic characteristics and stigma

The mean score for subscale 1 was significantly higher in unmarried/separated/divorced patients of schizophrenia as compared to the married ones. The potential of marriage in reducing certain kinds of mental health problems probably owes itself to the beneficial effects it confers in terms of increasing personal and social support.[18] Marriage improves social status and may decrease stigma.[28]

Significantly higher mean scores on subscale 3 (positive treatment) in the schizophrenia group were observed in the higher income group of the patients. These subscale items ask about times when the patient was treated more positively because of mental health problems. Previous studies also found higher socioeconomic status having comparatively lesser stigma and discrimination.[29],[30],[31] Patients with schizophrenia were treated more positively in the urban areas as compared to the rural areas, and the difference was statistically significant. However, as most patients with schizophrenia were from the urban background (96%), the conclusion may not be valid.

The scores of discrimination and stigma scales were similar on the sociodemographic characteristics (age, sex, current employment status, and income) and duration of illness in patients with BPAD. The only exceptions were residence and education. Rural patients had significantly higher mean scores on the subscale 3. Thus, people living in rural areas were trying more to overcome their stigma, hence leading to a decrease in stigmatization. The discrepancy and variability in the rural versus urban setting in experiencing stigma and discrimination by the patients suffering from mental illnesses have been studied and pointed out in the past studies also.[29],[30] A more benign attitude among rural populations toward persons with severe mental illness was present in some studies, which can explain so as to why people living in rural areas are less reluctant in accepting their disease, and this helps them in overcoming their stigma.[17],[18] Better educated BPAD patients had higher DISC scores compared to the less educated, perhaps because they were more acutely feeling discrimination in education- and employment-related activities.

Impact of duration of illness on stigma

In both schizophrenia and bipolar disorder patients, stigma was not related to the duration of illness. This finding was similar to a previous study where it was seen that the duration of illness was not associated with the level of stigma and discrimination.[22] This only emphasizes that irrespective of the duration of illnesses, mentally ill suffer stigma. In fact, some studies like that by Grover et al. suggest that stigma may be experienced more in the initial part of disease experience.[23]

What to do for reducing stigma?

Although mental health treatments and services have progressed and improved greatly over the past years, therapeutic advancements in psychiatry have not yet been able to reduce the associated stigma and discrimination. Stigma is a major risk factor causing negative mental health outcomes. Hence, it is of the utmost importance to do further research to understand the patterns of stigma and discrimination felt by patients suffering from various psychiatric diseases so that a custom-made plan can be worked out for each group, which will help us to move forward toward a stigma-free society.[32],[33] Now, we have evidence that various strategies can reduce stigma, for instance, for general population groups (where positive attitudinal change but perhaps less knowledge gains), for mentally ill patients (for whom antistigma group activities lead to a reduction in self-stigma), and for special groups such as college and high school students (in whom direct contact with recovered mentally ill). Although this evidence is limited for high-income countries, it should inspire studies in middle-income country like ours for efficacy in stigma reduction.[34] Summarizing the INDIGO network activities during the last decade, Thornicroft et al. mentioned that stigma and discrimination are universal, in that they are reversible and there are some variations in their manifestations across cultures.[35] For Indian researchers, it is a challenge to fill up the research gap.

There are only a few studies comparing discrimination and stigma between two mental illnesses and exploring their relationship with the sociodemographic characteristics in each group. The limitation of this study is a small sample size which cannot be extrapolated to the whole population.

Implications of the study

Irrespective of diagnosis, both severe psychiatry disorders are associated with considerable stigma. Most sociodemographic characteristics such as age, sex, education, employment status, marital status, income, and disease-related characteristics such as diagnosis and duration of illness do not predict stigma experience. Hence, there is a need for community-based antistigma interventions. Education (text, lecture, film, and role play), short-term and long-term face-to-face contact, parasocial contact protest, and structural approaches are some of the strategies.[35]

Although patients suffering from schizophrenia and bipolar disorder had equal unfair treatment from others, schizophrenic patients had stopped doing things because of their illness, had tried more to overcome the stigma, and were treated more positively. Stopping doing things may be related to self-stigma. There is a lack of evidence-based effective interventions for self-stigma, hence a need for further studies in this specific area.[35]


  Conclusions Top


It is important to assess stigma experiences and their impact from the perspective of people who are affected by mental illness, and it cannot be ignored. Various factors may affect the stigma and discrimination experienced by the mentally ill. We found being married to be associated with overcoming stigma easily. Delay in psychiatric treatment made the patients “Stopping self from doing things” such as doing work, applying for education and training, maintaining close interpersonal relationships, and revealing their mental health problems. Positive environmental factors have a mitigating effect especially on the “unfair treatment” by members of the family, society, or workplace.

Ethical statement

This study was approved by Institutional Ethics Committee with reference number DMIMS(DU)/IEC/2016-17/3047 obtained on 11th July 2016.

Declaration of Patient Consent

Patient consent statement was taken from each patient as per institutional ethics committee approval along with consent taken for participation in the study and publication of the scientific results / clinical information /image without revealing their identity, name or initials. The patient is aware that though confidentiality would be maintained anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



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



 

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