Mental illness stigma is still a worldwide psychiatric problem. Effective therapy for mental disorders can be obtained; however, there are several obstacles such as stigmatization against mentally ill patients that prevent them from obtaining the help they need to get better [20].
There are very limited studies performed in Upper Egypt that investigated the stigma of mental illness and its prevalence.
The current results revealed that there is a high prevalence of mental stigma among young patients (24 ± 5 years) consistent with the results of Hartini et al. [21] who found that the mean age of mental stigma is 23.3 years. This can explained by the fear of mental stigma affecting future career as well as the future marriage of young psychiatric patients studying, and conversely, when people age, they become more indulgent of their illness and its related issues. Our results are in contrast to the results of Zaske et al. [22] who postulated that elevated stigma experiences are associated with aging.
The findings of the current research suggest that female psychiatric patients (53.7%) reported a higher stigma score than male psychiatric patients (46.3%) which is consistent with the findings of Boge et al. [23] and Kinson et al. [24] who stated that female subjects displayed elevated perceived stigma levels than males and demonstrated that elevated perceived stigma levels of among female subjects could be due to cultural norms as well as female contributions to the family or the social system. Mental stigma is most common in females and can be explained by excessive anxiety as well as fear of being labeled mentally ill, thus losing her opportunity to get married or to find a job. In contrast, Gierk et al. [25] illustrated that male gender corresponds to higher mental health related stigma scores. Furthermore, Mutiso et al. [26] reported that people’s views regarding of mentally ill are the same for both women and men, and the differences in the findings may be related to cultural differences and how the society manages gender differences.
The findings of the current research support those of previous studies such as Hartini et al. [21] that higher mental stigma scores are more common among patients with low educational level (illiterate and less than high school) which is commonly associated with lower mental health literacy, and therefore has repercussions for the patient as he is not yet ready to make the right decisions what about to do when he/she has symptoms associated with mental illness. Through other means, patients with a lower educational level may have poor adaption methods or strategies to counter perceived stigmatization.
Our results revealed that patients living in rural areas (58.2%) reported higher mental stigma scores than patients living in urban areas (34.73%) which was evidenced by Townley et al. [27] who found that mental health stigma perceptions were more elevated in non-urban regions which can be attributed to several reasons such as fear of categorizing mentally ill patients into a small and closed community, low awareness levels, low education levels, lower socioeconomic status, cultural practices and beliefs, as well as the absence or inadequacy of mental health services. On the contrary, Mutiso et al. [26] mentioned that rural participants were more positive compared to those living in urban regions with regard to mental illness which could be attributed to the more demanding lifestyle in modern regions as well as fewer opportunities for mentally ill patients and finally the rapidly changing living conditions.
Regarding the marital status, the present study revealed that the number of single patients who recorded high stigma score (22.83%) is more elevated than those who recorded low stigma score (12.6%). While the number of married patients who recorded high stigma score (35.05%) is lower than those who recorded low stigma score (52.29%) which is in accordance with the results of Hartini et al. [21] who stated that married participants have greater tolerance toward mental illness than divorced or single subjects. However, Szczesniak [28] and Kalisova [29] could not detect any significant effect of marital status on the level of self-stigma.
The results of the current study demonstrated that the pervasiveness of elevated perceived stigma is high among unemployed participants (44.37%) than employed ones (26.34%) in parallel with the results of Kalisova [29] who found that unemployed patients have higher levels of self-stigmatization than employed patients. This can be attributed to the multiple discrimination that can impact job opportunities and help seeking among the mentally unemployed. In contrast, unemployment may result in a novel social identity which is stigmatized and correlated with impaired well-being [30].
In parallel with the study of Hartini et al. [21], our findings revealed that patients with low socioeconomic class recorded high stigma scores (59.49%) more frequently than those recorded low stigma scores (43.13%), which is in contrast to the results of Knesebeck [31] who demonstrated that people with low socioeconomic class to do not seem to experience a double public stigma with regard to emotional reactions, stereotypes, as well as desire for social distance compared to those of high socioeconomic class.
In our study, we found a positive association between longer duration of psychiatric illness (43 ± 8) and higher stigma scores in comparison to shorter duration of psychiatric illness (37 ± 9) recording low stigma scores which can be attributed to higher stigma scores. Since it is more common in psychotic disorders, because it is a chronic long standing disorder. Similar results were obtained by Szczesniak [28] who stated that disease duration was the only clinical parameter displaying a marked positive association with stigma internalization. In contrast, Kinson [24] found that discrimination as well as stigmatization are highly common among patients with first episode psychosis which may be related to different demographic variables, and level of functioning.
The present study revealed that mental stigma has a significant positive correlation with the number of psychiatric hospital admission which aligns with the findings of Xu et al. [32] and Michaela et al. [33] who reported that the self-stigma has been found to be significantly correlated with the number of hospitalizations as patients who have experienced more hospital admission are more likely to be discriminated besides experiencing more disorder attacks. Opposite results have been reported by Puamau [34] who mentioned that mental stigma is more common in the first psychiatric hospital admission.
In this research we found that patients with schizophrenia and other psychotic disorders who recorded high stigma scores (11.25% and 7.40% respectively) are more frequent than those who recorded low scores (6.49% and 3.05% respectively) which is compatible with results of Holubova [35] who stated that the individuals with neurotic spectrum disorders or depression had a lower degree of self-stigma compared to those with schizophrenia spectrum disorders. However, contrary results obtained by Loughman [36] denote that genetic and other biological aspects seem to have dual effects with regard to the stigma of mental disorders.
Our study revealed that patients with irregular psychiatric follow-up and those who did not adhere to medications got significantly high stigma scores (55.95% and 52.09% respectively). This is in agreement with Chaudhari [37] who illustrated that 52% of the psychiatric patients were low adherent to psychiatric medication as patients experience a sense of shame and stigma related to illness and treatment. In addition, Kearns [38] concluded that stigmatization of mental illness and attitudes toward seeking help are identified as barriers to obtaining professional aid. In this research, patients with high mental stigma scores showed a high frequency of suicidal thoughts or attempts (45.34%) similar to the results of Kucukalic [17] who stated that stigma as well as suicide are linked in two directions which means that suicide may result in stigma, nonetheless, stigma can also result in suicidal thoughts.
Strengths
There is limited research demonstrating the risk factors and the impact of mental stigma in our locality. The patients enrolled in the current were randomly chosen from the psychiatric clinic and a variety of other clinics. The range of the participants’ gender as well as age and diagnoses of the psychiatric disorder included indicate that we enrolled a wide range of users of mental health services.
Limitations of the study
The current study has a number of limitations; particularly that causality of the described relations cannot be explained. Sample size is small, and therefore, the research findings, particularly the results of the regression analysis, cannot be generalized. Some modifications can be made to the questionnaires such as adding multiple levels of fatigue and motivation of subjects.
Recommendations
There is an urgent need to confront stigma and thus mentally ill can be estimated as equal members of their communities. Then, development of psycho-educational as well as internet programs that concentrate on eliminating self-stigma. There is also a need for campaigns to improve mental health literacy as well as counter stigmatizing attitudes that may have beneficial effects in eliminating the desire for social distancing from mentally ill patients. The current study requires further assessment in larger groups of patients in distinct diagnostic cohorts to understand psychiatric stigma as well as its consequences.
