Archives of Psychiatric Nursing xxx (xxxx) xxx–xxx

Contents lists available at ScienceDirect

Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Self-stigma, mentally ill persons and health services: An integrative review

of literature
Bruna Sordi Carrara, Carla Aparecida Arena Ventura⁎
University of Sao Paulo at Ribeirao Preto College of Nursing, Ribeirao Preto, Brazil

A R T I C L E I N F O A B S T R A C T

Keywords: Integrative review about self-stigma among people with mental illness and its relationship with health services.
Self-stigma A total of 149 articles were found in four databases. After screening, 9 articles were selected for complete
Mentally ill persons reading and data extraction. The studies identified that higher levels of self-stigma result in lower levels of
Health services adherence to treatment and that lower levels of self-stigma result in greater adherence to treatment. Active
participation and engagement in the aspects of care facilitate the empowerment of people with mental illness for
better adherence to treatment, reduction of self-stigma and increase of recovery possibilities.

Introduction self-esteem leads to a sense of being less worthy of opportunities that

People with mental illness are challenged doubly. They struggle
with the symptoms and disabilities that result from the disease and also
are challenged by stereotypes and prejudice that result from mis-
conceptions about mental illness (Corrigan & Watson, 2002). People
with mental illness often internalize negative stereotypes, resulting in
self-stigma and low self-esteem. They may think: “people with mental
illness are bad and therefore I am bad, too” (Rüsch et al., 2009).
Self-stigma occurs when people internalize these public attitudes
and suffer numerous negative consequences as a result. In this aspect,
the individual becomes aware of the negative stereotypes that other
people attribute and necessarily agrees with these stereotypes and ap-
plies them to himself (Corrigan, Watson, & Barr, 2006).
According to Watson, Corrigan, Larson, et al. (2007), two self-
stigma implications deserve attention: self-devaluation, resulting from
the perception of inclusion in a devalued category and self-isolation, as
a consequence of the concern about how other people will respond to
their condition. When people perceive devaluation, they may avoid
situations where public disrespect is anticipated. The implications
therefore occur in a vicious cycle, in which aspects of recovery are
blocked in treatment, as well as other spheres of the individual's life, as
attempts to avoid stigmatization, causing a decrease in social support.
With the implications of self-stigmatization, there is a decrease in
self-esteem and self-efficacy, contributing to a lack of hope in achieving
life goals and worsening of the course of the mental illness (Link,
Phelan, Bresnahan, et al., 1999). Other consequence related to self-
stigmatization is what has been called the “why try” effect, in which
self-stigma functions as a barrier to achieving life goals. Diminished
undermine efforts of independence (Corrigan, Larson, & Rüsch, 2009).
However, not all people with mental illness internalize public
stigma. Some people do not perceive and/or do not annoy with its ef-
fects. In addition, some people feel outraged by public stigma and seek
justice and, therefore, are seen as encouraging dealing with the nega-
tive consequences of stigma. This attitude is associated with high self-
esteem, better quality of life and increased social support (Corrigan,
Faber, Rashid, et al., 1999).
The process of stigmatization of people with mental illness has
consequences to interpersonal relations, considering the set of negative
attributes involved, stimulating a generalized undesirability
(Link & Phelan, 2001). The desire for social distance is considered a
determining factor in the way people with mental illness are treated, as
the symptoms of a mental illness are associated with perceived danger.
These people are negatively affected by rejection, what generates dis-
tancing and exclusion, also compromising the search for help, ad-
herence to treatment and social integration (Link & Phelan, 2001;
Peluso & Blay, 2004). Even as public stigma, self-stigma has con-
sequences such as emotional reactions and negative behaviors that di-
rectly interfere in health care and can act as a barrier to the access to
health care and treatment adherence.
In this sense, the aims of this study are to identify, critically evaluate
and synthesize the evidences pointed out in the literature about self-
stigma among people with mental illness and its relationship with
health services. This review may contribute to the understanding of
self-stigma among people with mental illness as a barrier to their re-
lationship with health services.

⁎
Corresponding author at: University of Sao Paulo at Ribeirao Preto College of Nursing, Avenida Bandeirantes, 3900, Bairro Monte Alegre, CEP: 14040-902, Ribeirao Preto, Brazil.
E-mail address: caaventu@eerp.usp.br (C.A.A. Ventura).

http://dx.doi.org/10.1016/j.apnu.2017.11.001
Received 27 August 2017; Received in revised form 26 October 2017; Accepted 2 November 2017
0883-9417/ © 2017 Elsevier Inc. All rights reserved.

Please cite this article as: Carrara, B.S., Archives of Psychiatric Nursing (2017), http://dx.doi.org/10.1016/j.apnu.2017.11.001
B.S. Carrara, C.A.A. Ventura
Method
Integrative review
Integrative review based on the method of Whittemore and Knafl
(2005), carried out through publications that investigated, in the con-
text of health services, the phenomenon of self-stigma in people with
mental illness. Integrative review combines data from different types of
research, including empirical or theoretical studies, focusing on meth-
odology, theory and results (Whittemore & Knafl, 2005). The self-
stigma in people with mental illness and its relationship with health
services was summarized and analyzed with the purpose to draw gen-
eral conclusions about the phenomenon. This integrative review is
important for future interventions to reduce self-stigma in people with
mental illness.
2
Archives of Psychiatric Nursing xxx (xxxx) xxx–xxx
Fig. 1. Flow of information: integrative review ac-
cording to databases and full texts captured.
Problem identification
The self-stigma among people with mental illness and their re-
lationship with health services was the problem identified to conduct
the integrative review. The guiding question for the integrative review
was identified as: What is relationship between self-stigma in people
with mental illness and health services? The question was formulated
using the PICo strategy (P: patient or problem, I: intervention, Co:
context) (Briggs, 2014), which consisted of: P (people with mental ill-
ness), I (internalized stigma/stigma), Co (health services).
Data search
In consultation with a health science reference librarian relevant
databases were identified and search terms were refined. The electronic
B.S. Carrara, C.A.A. Ventura
databases were Pubmed, Web of Science (multidisciplinary databases
that index articles of high impact factor), CINAHL (data base of the
Nursing area) and LILACS, (data base of relevance in Latin America). In
the search for the literature related to the proposed theme, the quali-
fication of the process occurred through the search for descriptors
through MeSH (Medical Subject Headings) and DeCS (Health Sciences
Descriptors). The vocabularies used were (‘self-stigma’ OR ‘internalized
stigma’) AND (‘mentally ill persons’ OR ‘mental disorder’) AND (‘health
services’ OR ‘health care’). In database LILACS, terms in Portuguese
were used in the search.
The inclusion criteria for the selected studies were: articles with
samples of people with mental illness and their relation with self-stigma
and health services; articles published in English, Spanish and
Portuguese; and primary studies retrieved in the databases from 1992
to 2015. The exclusion criteria adopted were the impossibility of ac-
quiring the article, those classified as editorials, theses or dissertations
and those that did not correspond directly to the theme. Articles were
submitted to a pre-selection by reading the title and abstract, con-
tributing to selecting the list of studies associated with the guiding
question. Nine studies focused on the self-stigma of people with mental
illness in the context of health services. A large number of articles were
excluded (n = 140), as they were not related to the proposed objective
and focused on themes such as: 1) relation of stigma, mental illness and
work; 2) relation of stigma, mental illness and different groups of
people; 3) experiences related to mental illness; 4) relationship between
stigma and health services; 5) relationship of stigma and different
health conditions (HIV, obesity, infertility, epilepsy, suicide); 6) self-
stigma not associated with health services.
Data evaluation
This integrative review was conducted by two independent re-
viewers according to the established criteria (Cooper, 1982;
Polit & Beck, 2012). A total of 149 articles were found in databases. One
hundred thirty two remained after duplicates were removed. Following
title screening, 83 articles were excluded and 35 studies were selected
for title and abstract review. After this pre-selection, with the filtering
of articles by means of readings, 26 articles were excluded and 9 articles
were identified as potentially eligible (Fig. 1).
For data evaluation, methodological assessment tools (Table 1) were
adapted from the literature (Ursi & Galvão, 2006) to extract information
from the studies. For the analysis of the rigor of the studies, the Briggs'
(2014) instrument was used.
Data analysis
The articles' contents were analyzed, sorted, codified, categorized
and summarized in a unified and integrated conclusion, according to
the instrument developed by Ursi and Galvão (2006). The articles were
classified according to authors, origin and year of publication, sample
Table 1
Adapted table from Ursi's instrument.
Identification Author
Year
Country
Title
Origin
Language
Methodological characteristics Purpose
Design
Sample
Instruments
Findings
Evidence Level
Rigor evaluation Limitations identified
Studies rigor
3
Archives of Psychiatric Nursing xxx (xxxx) xxx–xxx
characteristics, objectives, methods and main results (Table 2).
The selected articles' contents were categorized by the identification
of ideas related to the interpretation of data, such as: self-stigma and
low adherence to treatment, low self-stigma and high adherence to
treatment, empowerment, agreeing with stigmatization, direct and in-
direct impacts of self-stigma, factors such as socio-demographic data,
psychiatric conditions (clinical condition) and awareness of the condi-
tion (Fig. 2).
Results
The studies identified that higher levels of self-stigma result in lower
levels of adherence to treatment and that lower levels of self-stigma
result in greater adherence to treatment. Of these, one study indicated
that acceptance of the disease contributes to dealing with self-stigma.
Besides, there was one study that reported a low correlation between
the levels of self-stigma and socio-demographic factors.
Of the selected articles (n = 9), most are quantitative studies
(n = 8), only one (n = 1) was classified as mixed (quantitative and
qualitative). The studies were conducted mainly in China (n = 3) and
the United States (n = 3) followed by the Czech Republic (n = 1),
Ethiopia (n = 1) and Canada (n = 1). Most studies had a unique sample
of people with schizophrenia (n = 5), followed by studies that classified
the sample with people with severe mental illness (n = 3). There was
only one study (n = 1) that did not justify its sample. The majority of
quantitative studies used evaluation tools such as scales and ques-
tionnaires (n = 9), and the study classified as mixed added the use of
interview. Only five studies reported the reliability of the instruments
and two reported content validity. We observed a prevalence of de-
scriptive studies (level of evidence IV), that showed low level of sci-
entific evidence (Fineout-Overholt, Williamson, Gallagher-Ford, et al.,
2011). Studies were recently published and in English.
Discussion
The reading of the selected articles enabled the visualization of the
self-stigmatization process divided into two aspects in reference to self-
stigma among the mentally ill and their relationship with health ser-
vices: the levels of self-stigma and their implications to the adherence to
treatment and other aspects in the life of the mentally ill person and the
factors associated with self-stigma and the use of health services.
Levels of self-stigma and their implications to the adherence to treatment and
other aspects in the life of the mentally ill person
Stigmatization is one of the main factors inhibiting the use of health
services and the adherence to treatment (Corrigan, Lurie, Goldman,
et al., 2005; Zartaloudi & Madianos, 2010). People with mental illnesses
who internalize stigma, accept negative images associated with mental
illnesses, agree with the stereotypes and endorse the idea of
Who conducted the study?
When was the study conducted?
In what country was the study conducted?
What is the title?
What was the origin?
What is the language?
What were the objectives of the study?
What was the study design? Was the study longitudinal, cross-sectional?
What was the sample of the study?
What type of instrument was used to measure self-stigma?
What were the findings of the study?
What was the evidence level of the studies?
What were the strengths and limitations of the study?
The methodological steps were clearly described?
 Table 2
Authors, origin and year of publication, sample characteristics, goals, methods, and main results.

Authors/origin/year Objectives Method Sample Main findings

Vrbova et al. To determine if there is a relationship between Objective and subjective Clinical Global Impression – 74 patients diagnosed with schizophrenia The levels of self-stigma as assessed by the total
Neuroendocrinology psychoactive drug discontinuation, adherence Severity scale, Drug Attitude Inventory, Internalized spectrum disorders (schizophrenia, ISMI scores were not statistically significantly
Letters to current treatment and self-stigma in a sample Stigma of Mental Illness (ISMI) scale and demographic schizoaffective disorder, delusional disorder) correlated with most of the demographic
B.S. Carrara, C.A.A. Ventura

2014 of 90 outpatients diagnosed with psychotic
Czech Republic illness
Tsang To examine the relationship between stages of
Hong Kong Med J change, self-stigma, introspection, self-esteem,
2013 and adherence to psychosocial treatment
China among Chinese adults with schizophrenia;
Develop a program to reduce self-stigma and
improve readiness for change and adherence to
treatment; To test the effectiveness of the
reduction
ASSEFA et al. To evaluate the extent of internalized stigma in
BMC Psychiatry patients with schizophrenia who attend the
2012 outpatient clinic of a psychiatric hospital in
Ethiopia Ethiopia; Determine which socio-demographic
factors are associated with the stigma
experience, and explore the impact of stigma on
adherence to treatment
Livingston, Rossiter, Verdun- To evaluate the extent to which the provision of
data
Cross-sectional study (for relationship exploration) and
entailed a randomised controlled trial (in the form of a
self-stigma reduction programme). Psychosocial
Treatment Compliance Scale (PTCS), the Brief
Psychiatric Rating Scale (BPRS), the Global Assessment
of Functioning Scale (GAF), the Chinese Self-stigma of
Mental Illness Scale (CSSMIS), the Change Assessment
Questionnaire for People with Severe and Persistent
Mental Illness (CAQ-SPMI), the Scale to Assess
Unawareness of Mental Disorders (SUMD), and the
Chinese General Self-efficacy Scale (CGSS)
Cross-sectional study; Internalized Stigma of Mental
Illness (ISMI) scale
The design with a quantitatively driven mixed methods
regularly attending a psychiatry department
outpatient center
51 men and 54 women with schizophrenia
Individuals with a diagnosis of schizophrenia
91 individuals (52 forensic, 39 civil) who
factors. There was a significant negative
correlation with current adherence to
treatment.
It is important to consider the characteristics
and daily experience of participants when
designing the treatment protocol. A supportive
environment to liaise with participants'
corresponding service units should be fostered.
Furthermore, helping individuals with
schizophrenia to develop a sense of urgency
enables them to accept their illness and reject
mental illness stigma
Internalized stigma is a major problem among
persons with schizophrenia in this outpatient
setting in Ethiopia. Internalized stigma has the
potential to substantially affect adherence to
medication and is likely to affect the recovery
process
The ‘forensic’ labeling was not associated with

4
Jones services through a specialized forensic mental approach that included a simultaneous qualitative received compulsory community treatment elevated levels of self-stigma. Quantitative
Psychiatry Research health system contributes to self-stigma supplemental component (QUAN + qual) structured services within either the civil or forensic level of self-stigma was significantly associated
2011 experiences among users of forensic services interviews Standardized, quantitative measures Behavior mental health systems with psychiatric symptom severity, history of
Canada and Symptom Identification Scale-24 (BASIS-24); incarceration, and history of homelessness. The
Wisconsin Quality of Life Index (WQL); Camberwell access to high-quality, well-resourced forensic
Assessment of Need (CANFOR); Internalized Stigma of mental health services may, for some service
Mental Illness (ISMI) scale users, combat the risk of increased exposure to
social and structural stigma
Tsang, Fung, Chung To investigate the relationship between self- Questionnaires Chinese Self-stigma of Mental Illness 105 patients with schizophrenia The findings supported the direct effects of self-
Psychiatry Research stigma, stages of change, and adherence to Scale (CSSMIS); Scale to assess unawareness of mental stigma on reducing psychosocial treatment
2010 treatment among individuals with disorders (SUMD); Change assessment questionnaire for adherence, and its indirect influences mediated
Hong Kong schizophrenia people with severe and persistent mental illness (CAQ- by insight and stages of change on treatment
SPMI); Psychosocial treatment compliance scale (PTCS); adherence. Psychopathology was also found to
Brief psychiatric rating scale (BPRS) have a direct effect on undermining adherence
Fung, Tsang, Chan To explore the association between self- A cross-sectional study. Face-to-face interviews 105 adults with schizophrenia Individuals with higher global functioning,
Soc Psychiat Epidemiol stigmatization and adherence to treatment better readiness for action, and lower level of
2010 through track analysis with a vision and self-stigma demonstrated better treatment
Hong Kong readiness for change conceptualized as possible participation
mediators
Rüsch et al. To analyze the impact of self-stigma and stigma Subscale of the self-stigma of mental illness scale; 85 participants with mental illness The self-stigma and stigma-related cognitions
The British Journal of on the use of health services perceived devaluation–discrimination questionnaire; predict service use among people with serious
Psychiatry symptom check list–revised and chronic mental illness, independent of
2009 baseline psychopathology, diagnosis and the
USA level of perceived stigma. Cognitions
associated with resilience to stigma may
facilitate use of out-patient services and be
more relevant to help-seeking than the level of
perceived stigma per se
(continued on next page)
Archives of Psychiatric Nursing xxx (xxxx) xxx–xxx
B.S. Carrara, C.A.A. Ventura Archives of Psychiatric Nursing xxx (xxxx) xxx–xxx

stigmatization (Link & Phelan, 2001). This process generates a reduc-

Better self-esteem and current insight about the

adults in urban areas even after accounting for

negative social consequences were significant

isolated rural counties demonstrated higher

Results indicated that older adults living in
tion in self-esteem and self-efficacy (Corrigan, 2004), which are factors

levels of psychological openness than older

predictors of better psychosocial treatment

levels of public and self-stigma and lower

participation. Self-stigma and self-esteem
that influence the use of health services.

exhibited the strongest contributions to

education, employment, and income

Therefore, there is a direct relationship between self-stigma and low

psychosocial treatment adherence

adherence to treatment (medicated or psychosocial). In this integrative
review, studies in which scales with the objective of measuring the level
of self-stigma were used (Assefa, Shibre, Asher, et al., 2012; Fung,
Tsang, & Corrigan, 2008; Rüsch, Corrigan, Wassel, et al., 2009; Tsang,
2013; Tsang, Fung, & Chung, 2010; Vrbová, Kamarádová, Látalová,
et al., 2014), revealed high levels of self-stigma in people with mental
Main findings

illnesses and low levels of adherence to treatment. According to these

authors, a possible reason for the relationship between high levels of
self-stigma and low levels of adherence to treatment is that people with
mental illnesses want to hide their diagnosis to avoid discrimination.
Only one study (Livingston, Rossiter, & Vedun-Jones, 2011) found low
levels of self-stigma, verifying that people who receive services in the
86 people with DSM IV diagnoses of

forensic mental health system may encounter fewer barriers to their

access to services than those within the civil mental health system.
The social-cognitive model of self-stigma (Corrigan, 2004) explains
that in people belonging to a stigmatized group, stigmatizing attitudes
against themselves are a result of their agreement with stereotypes, of
self-prejudice and self-discrimination. However, there is a paradox re-
schizophrenia

garding self-stigma and mental illnesses in relation to empowerment

121 adults

from their own condition: there are people with mental illnesses who,
Sample

despite limitations, are not prejudiced when faced with stigma and
show no negative consequences. On the other hand, there are people
with mental illnesses that are strongly influenced by pessimistic ex-
Stigmatization by Others for Seeking Psychological Help;
Mental; Illness Scale (CSSMIS); The 23-item Self-Efficacy

pectations with respect to their condition and possibilities of treatment.

Inventory of Attitudes Toward Seeking Mental Health
Compliance Scale (PTCS); The Chinese Self-Stigma of

Self-Stigma of Seeking Help (SSOSH); Perceptions of

This aspect was revealed in the majority of the studies found in this
Multiple Regression; The Psychosocial Treatment;

review, showing high levels of self-stigma and is in line with the lit-
erature which shows two principal implications of self-stigma: the
perception of belonging to a supposedly socially devalued category,
leading to self-devaluation, and concerns of people with mental ill-
nesses as to how other people will react to their conditions, which leads
to engagement in defenses, isolation and other negative consequences
(Watson et al., 2007).
According to Fung et al. (2007), there is a mutual influence between
stigma internalization and self-stigma, in which self-stigma unchains
diminished self-esteem, which in turn increases the negative percep-
Scale (SES)

tions about oneself, reinforcing stigma internalization. However, in one

Services
Method

of the selected studies (Tsang et al., 2010), self-efficacy in people with

schizophrenia did not constitute a significant predictor of adherence to
treatment.
To examine the relationship between adherence

geographically isolated rural area, a rural area

adjacent to a metropolitan area, and an urban

In relation to the consequences of self-stigma at an individual level,

stigma, self-esteem, self-efficacy, insight, and

community sample of elderly residents in a

To examine self-stigma, public stigma, and
certain sociodemographic variables among

there are direct impacts, such as low levels of adherence to treatment,

to psychosocial treatment and self-stigma,

attitudes toward mental health care in a

and indirect impacts, such as the resulting negative psychological me-

chanisms (low self-esteem, self-efficacy, demoralization, hopelessness,
depression and poor insight into beneficial effects of treatment).
However, the effects of seeking care are originated from the interaction
patients with schizophrenia

between public stigma and self-stigma (Corrigan, 2004).

The direct and indirect impacts were shown in the analyzed studies
(Fung et al., 2008; Fung, Tsang, & Chan, 2010; Livingston et al., 2011;
Rüsch et al., 2009; Tsang, 2013; Tsang et al., 2010; Vrbová et al., 2014),
Objectives

in agreement with other research (Corrigan, 2004; Vogel, Bitman,

Hammer, et al., 2013), which identified that those that avoid the la-
area

beling associated with mental illness also seek to avoid negative emo-
tional reactions, reducing participation in treatment. In other words, on
Psychiatric Rehabilitation

the one hand, people with mental illnesses avoid labeling in order to
Psychological Services

escape the impact of stigma, but on the other hand, avoid the treatment
Stewart, Jameson, Curtin
Fung, Tsang, Corrigan

due to the label that goes with it. These results are compatible with data
Authors/origin/year

from the literature (Fung et al., 2007), which identified that low self-
Table 2 (continued)

esteem leads to feelings of hopelessness and disbelief in the benefits of

Journal

treatment, resulting in low adherence to treatment.

2008

2015
USA

USA

According to Lysaker, Salyers, Tsai, et al. (2008), hopelessness is a

characteristic that is highly affected by self-stigma, constituting a bar-
rier to treatment. An exploratory study by the same authors showed

5
B.S. Carrara, C.A.A. Ventura
Fig. 2. Identified units in data interpretation and construction of categories.
that people with schizophrenia or schizoaffective disorder, with low
levels of hope, are more susceptible to the impacts of self-stigma or to
the exacerbation of symptoms. Studies from this review (Assefa et al.,
2012; Fung et al., 2010; Rüsch et al., 2009; Tsang, 2013) that also in-
vestigated aspects of self-stigma in people with schizophrenia or schi-
zoaffective disorders revealed similar data in relation to indirect im-
pacts and adherence to treatment.
Therefore, self-stigma in the mentally ill directly influences access
to health services and has implications in adherence to treatment and in
diverse aspects of life.
Factors associated with self-stigma and the use of health services
Some variables influence the association between the use of health
6
Archives of Psychiatric Nursing xxx (xxxx) xxx–xxx
services and self-stigma in people with mental illnesses. According to
Corrigan (2004), negative reactions of family members, demographic
data (older people) and social data (education, poverty) are among the
variables considered. According to Thornicroft, Brohan, Kassam, et al.
(2008) and Yen, Chen, Lee, et al. (2005), the socio-demographic vari-
ables related to high levels of self-stigma are: male, low level of edu-
cation, unemployment, poor social support, long duration and ser-
iousness of the illness.
The demographic data that appeared in some studies in this review
(Vrbová et al., 2014; Tsang, 2013; Assefa et al., 2012; Stewart,
Jameson & Curtin, 2015), such as factors that may influence self-stigma
and adherence to treatment, showed divergences. Assefa et al. (2012)
and Stewart, Jameson and Curtin (2015) agree that living in a rural
area diminishes adherence to treatment and increases the level of self-
B.S. Carrara, C.A.A. Ventura
stigma. However, Vrbová et al. (2014) did not identify the same asso-
ciation. In this study, the fact of having a partner is not a protective
factor against low adherence to treatment, while in the work of Assefa
et al. (2012) this factor reduces the chances of interrupting treatment,
also diminishing the level of self-stigma.
The only study that indicated that having a high level of education
is a protective factor against self-stigma was Assefa et al. (2012), that
was in accordance with previous studies (Adewuya, Owoeye,
Erinfolami, et al., 2010; Brohan, Gauci, & Sartorius, 2010; Werner,
Stein-Shvachman, & Heinik, 2009; Yen et al., 2005) that reported a
significant association between low levels of education and elevated
self-stigma.
In relation to the level of self-stigma, the severity of the psychiatric
condition and adherence to treatment, Vrbová et al. (2014) and Rüsch
et al. (2009) found the independence of the seriousness of the symp-
toms in influencing self-stigma and adherence to treatment. On the
other hand, Assefa et al. (2012) and Fung et al. (2010) indicated that
the more serious are the symptoms, the greater the self-stigma and the
lower the adherence to treatment, data which is in line with the results
of studies by Thornicroft et al. (2008) and Yen et al. (2005).
The study by Fung et al. (2008) showed that having greater
awareness of one's mental illness increases adherence to treatment and
diminishes the level of self-stigma. This aspect is coherent with the
orientations of Corrigan et al. (2014), who emphasizes that the impact
of awareness of mental illness should be examined, as many people
without awareness suffer influence in the functional domains of life,
such as seeking treatment with health services.
In accordance with Corrigan et al. (2005), when dealing with
mental illnesses, three aspects that influence self-stigma should be
taken into consideration: 1) the negative emotional reactions that result
in self-stigma should be differentiated from common emotional reac-
tions in depressive disorders; 2) the awareness of having an illness can
be prejudiced during a symptomatic episode, leading to stigmatizing
reactions; 3) the reaction of an individual to a stigmatizing environment
is dependent on the perception of subtle stigmatizing messages from
other people.
Therefore, one of the consequences of the stigmatization process of
people with mental illness is stigma internalization, that is, it is the
public stigma's manifestation in the individual (Corrigan et al., 2006).
Results of this review indicate that negative emotional reactions and
low adherence to treatment are effects of self-stigma among people with
mental illness. Interventions targeting health care professionals must
increase awareness of how actions can have a stigmatizing impact on
patients and the importance of minimizing negative impacts on people
with mental illness. We know that health professionals, especially
nurses, who are in close contact with patients in different health ser-
vices, can play a key role in treatment, recovery and improvement of
the quality of life of people with mental illness. Nurses, in addition to
being able to understand the individual as a singular being, must be
recognized for the capacity to understand the needs and expectations of
users who seek for care at health services (Rangel, Fugali, Backes,
Gehlen, & Souza, 2011). “Understanding” should be a tool for the hu-
manization of health services, based on listening and the purpose of
building links with people when providing care (Costa,
Garcia, & Toledo, 2016). These actions may contribute to the reduction
of self-stigma.
Conclusion
As there is concern regarding stigmatization of people with mental
illnesses influencing their relationship with health services and in re-
gard to stigmatization invading the individual level through the process
of self-stigma in people with mental illnesses, this integrative review
identified a reduced number of studies analyzing the relationship be-
tween self-stigma in people with mental illness and health services. The
majority of these studies focused on the relationship between self-
7
Archives of Psychiatric Nursing xxx (xxxx) xxx–xxx
stigma and adherence to treatment among people with mental illnesses.
The limitations of the study are related to its broader results. We
searched the relationship between self-stigma in people with mental
illness and health services, and did not specify types of mental illness or
health services. Therefore, the implications for practice, intervention
and investigation are presented broadly and general.
According to the studies, future research may determine the impact
of the personal level of stigma on healthcare and quality of life, examine
the impact of awareness of a mental illness on self-stigma and ad-
herence to treatment, demonstrate causal relationships connected to
self-stigma, determine how pre-existing attitudes influence seeking
healthcare, adopt broader models of seeking healthcare and use re-
search methods that integrate psychological and sociological con-
structs.
The studies also indicated that one way to reduce the effects of self-
stigma, such as the low level of adherence to treatment and negative
emotional reactions, is individual level interventions, aiming at mini-
mizing the internalization of public stigma. These interventions should
focus on changing self-stigma, altering stigmatizing beliefs and atti-
tudes of the individual and constructing skills to deal with self-stigma.
Active participation and engagement in all aspects of care facilitates the
empowerment of persons with mental illness to improve adherence to
treatment, diminishing self-stigma and increasing the possibility of re-
covery.
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