Social Science & Medicine 71 (2010) 2150e2161

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Social Science & Medicine

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

Correlates and consequences of internalized stigma for people living with mental
illness: A systematic review and meta-analysis
James D. Livingston a, b, *, Jennifer E. Boyd c
a
Forensic Psychiatric Services Commission, BC Mental Health & Addiction Services, Provincial Health Services Authority, 70 Colony Farm Road,
Port Coquitlam, British Columbia, Canada V3C5X9
b
School of Criminology, Simon Fraser University, British Columbia, Canada
c
Department of Psychiatry, University of California/San Francisco and San Francisco VA Medical Center, California, USA

a r t i c l e i n f o a b s t r a c t

Article history: An expansive body of research has investigated the experiences and adverse consequences of internal-
Available online 12 October 2010 ized stigma for people with mental illness. This article provides a systematic review and meta-analysis of
the extant research regarding the empirical relationship between internalized stigma and a range of
Keywords: sociodemographic, psychosocial, and psychiatric variables for people who live with mental illness. An
Stigma exhaustive review of the research literature was performed on all articles published in English that
Mental illness
assessed a statistical relationship between internalized stigma and at least one other variable for adults
Meta-analysis
who live with mental illness. In total, 127 articles met the inclusion criteria for systematic review, of
Systematic review
which, data from 45 articles were extracted for meta-analyses. None of the sociodemographic variables
that were included in the study were consistently or strongly correlated with levels of internalized
stigma. The review uncovered a striking and robust negative relationship between internalized stigma
and a range of psychosocial variables (e.g., hope, self-esteem, and empowerment). Regarding psychiatric
variables, internalized stigma was positively associated with psychiatric symptom severity and nega-
tively associated with treatment adherence. The review draws attention to the lack of longitudinal
research in this area of study which has inhibited the clinical relevance of findings related to internalized
stigma. The study also highlights the need for greater attention on disentangling the true nature of the
relationship between internalized stigma and other psychosocial variables.
Ó 2010 Elsevier Ltd. All rights reserved.

Introduction understanding, or explicit articulation, of its conceptual ingredients

Stigma is an insidious social force that has been associated with
an endless number of attributes, circumstances, health conditions,
and social groups e with the literature primarily concentrated on
race, sexuality, mental illness, and HIV/AIDS (Manzo, 2004). The
focus of this paper is on the stigma of mental illness. More specif-
ically, it investigates the correlates and consequences of internal-
ized stigma, also known as self-stigma, for people living with
mental illness.
Conceptual clarity regarding ‘stigma’ is lagging behind the
burgeoning body of research regarding its effects. As others have
highlighted (Link & Phelan, 2001; Parker & Aggleton, 2003), social
scientists too often study stigma without an apparent
* Corresponding author. Forensic Psychiatric Services Commission, BC Mental
Health & Addiction Services, Provincial Health Services Authority, 70 Colony Farm
Road, Port Coquitlam, British Columbia, Canada V3C5X9. Tel.: þ1 6045247725.
E-mail address: jlivingston@forensic.bc.ca (J.D. Livingston).
and boundaries. Manzo (2004) asserted that stigma is consistently
“underdefined and overused” (p. 401). In a similarly critical fashion,
Prior, Wood, Lewis, and Pill (2003) highlighted the adverse conse-
quences of using stigma as an all-encompassing concept: “Stigma,
we suggest, is creaking under the burden of explaining a series of
disparate, complex and unrelated processes to such an extent that
use of the term is in danger of obscuring as much as it enlightens”
(p. 2192). This is particularly problematic as governments and
professional organizations mobilize resources toward preventing
and managing “this thing called stigma” (Manzo, 2004, p. 413).
Erving Goffman’s conceptualization of ‘stigma’ has germinated
over forty years of a blossoming body of theory and research. In his
seminal work, Stigma: Notes on the Management of Spoiled Identity,
Goffman (1963) referred to stigma as: “an attribute that is deeply
discrediting” (p. 3), “an undesired differentness” (p. 5), and some-
thing that reduces the bearer “from a whole and usual person to
a tainted, discounted one” (p. 3). The utility of Goffman’s concep-
tualization for understanding health-related stigma within the

0277-9536/$ e see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2010.09.030
 J.D. Livingston, J.E. Boyd / Social Science & Medicine 71 (2010) 2150e2161
context of contemporary society has been challenged (Sayce, 1998;
Scambler, 2006). For example, Weiss, Ramakrishna, and Somma
(2006) have outlined several shortcomings in Goffman’s formula-
tion, including: the outdated language and concepts, the over-
generalized application of stigma to an array of circumstances
unrelated to health, the failure to account for variability in stigma
experiences, the incompatibility of his analytic framework with
today’s multicultural or pluralistic societies, and the over-emphasis of
dyadic social interactions at the expense of structural considerations.
More recently, authors have reframed the concept to improve its
relevance for studying the social dimensions of public health prob-
lems in the context of modern globalization and multiculturalism
(Corrigan, Kerr, & Knudsen, 2005; Corrigan, Watson, & Barr, 2006;
Herek, 2004; Herek, 2007; Herek, Gillis, & Cogan, 2009; Link &
Phelan, 2001). In particular, contemporary conceptualizations have
paid greater attention to the socio-cultural processes and structures
that sustain stigma, as well as the factors (including features of the
disease) that produce variability in how it is experienced and
expressed (Herek, 2007; Parker & Aggleton, 2003; Scambler, 2009;
Weiss et al., 2006).
The literature articulates three interacting levels of stigma: social,
structural, and internalized (Corrigan, Kerr et al., 2005; Herek, 2007;
Herek et al., 2009). Social stigma, also known as public or enacted
stigma, exists at the group (i.e., meso) level and describes “the
phenomenon of large social groups endorsing stereotypes about and
acting against a stigmatized group” (Corrigan, Kerr et al., 2005, p.
179). Structural stigma, also called institutional stigma, exists at the
systems (i.e., macro) level and refers to the rules, policies, and
procedures of private and public entities in positions of power that
restrict the rights and opportunities of people with mental illness
(Corrigan, Kerr et al., 2005; Corrigan, Watson et al., 2005). In this
form of stigma, “cultural ideology [is] embodied in institutional
practices” (Herek, 2007, p. 907) so that differentials in power and
status are legitimated, and disadvantage and social exclusion are
perpetuated (Corrigan, Kerr et al., 2005; Herek, 2007; Herek et al.,
2009).
Internalized stigma, also referred to as self or felt stigma, exists at
the individual (i.e., micro) level and, in the context of mental illness,
can be described as a process whereby affected individuals endorse
stereotypes about mental illness, anticipate social rejection,
consider stereotypes to be self-relevant, and believe they are
devalued members of society (Corrigan, Kerr et al., 2005; Corrigan
& Watson, 2002, Corrigan et al., 2006; Ritsher & Phelan, 2004).
Further distinctions have been made between felt and self stigma
(Herek, 2007; Herek et al., 2009). Whereas felt stigma describes
negative consequences resulting from an individual’s awareness of
how society perceives, and will likely act toward, the group to
which they belong (e.g., homosexual, mentally ill), self-stigma
refers to the process of an individual accepting society’s negative
evaluation and incorporating it into his or her own personal value
system and sense of self. Similarly, distinctions have been made
between perceived stigma (awareness of stereotypes) and self-
stigma, with the latter being defined as: “when the person inter-
nalizes the stigma and applies it to people with mental illness in
general (stereotype agreement) or to him or herself (self-concur-
rence)” (Corrigan et al., 2006, p. 882). The processes and factors that
are involved in internalized stigma for people with mental illness
have been elucidated in several models, including Corrigan and
Watson’s (2002) situational model and Link, Struening, Cullen,
Shrout, and Dohrenwend’s (1989) modified labelling theory.
Weiss et al. (2006) define health-related stigma as: “a social
process, experienced or anticipated, characterized by exclusion,
rejection, blame, or devaluation that results from experience,
perception or reasonable anticipation of an adverse social judg-
ment about a person or group” (p. 280). Drawing primarily from
2151
this definition, the present study defines internalized stigma as
a subjective process, embedded within a socio-cultural context,
which may be characterized by negative feelings (about self),
maladaptive behaviour, identity transformation, or stereotype
endorsement resulting from an individual’s experiences, percep-
tions, or anticipation of negative social reactions on the basis of
their mental illness. The strength of this definition is that it
recognizes the macro-socio-cultural forces that influence this
subjective, individualized process (Yang et al., 2007). As well, this
conceptualization pays attention to the multi-faceted dimensions
of internalized stigma (Link & Phelan, 2001), which involves
interacting processes at the individual and societal levels. This
definition encompasses the various conceptualizations of inter-
nalized stigma embodied in studies that were included in the
present review (see below).
An expansive body of qualitative and quantitative research has
investigated the experiences of internalized stigma for people with
mental illness. The fruition of this effort has manifested in the
accumulation of findings regarding the factors and domains that
are implicated in the process of internalized stigmatization. It is
clear that, by impeding recovery and compounding suffering,
internalized stigma presents a serious problem for many people
who live with mental illness. In order to learn from this rapidly
growing body of literature, it is time to take stock of these findings
and identify the existence of trends in research relating to inter-
nalized stigma. Reviews have been completed with other stigma-
tizing conditions, including HIV (Logie & Gadalla, 2009) and
a combination of others (Mak, Poon, Pun, & Cheung, 2007; Van
Brakel, 2006). As well, narrative reviews have been performed on
stigma research relating to mental illness. For example, Link, Yang,
Phelan, and Collins (2004) provided a comprehensive review of the
tools that researchers have used to assess mental illness stigma
among several groups, including the general population, children
and youth, health professionals, and people with mental illness.
More recently, Brohan, Slade, Clement, and Thornicroft (2010)
published a review of measures that are designed to assess
stigma experiences among people with mental illness. A narrative
review by Overton and Medina (2008) describes the effects of
various forms of mental illness stigma (e.g., social, structural);
however, the findings related to internalized stigma are not
reviewed in a comprehensive or systematic manner.
The present review represents the first systematic synthesis of
research findings relating specifically to internalized stigma of
mental illness. The present study evaluates the sociodemographic,
psychosocial, and psychiatric variables that quantitative research
has demonstrated to have an empirical relationship with inter-
nalized stigma for people who live with mental illness. In addition
to providing a solid foundation for stigma researchers, this
advancement will help policy-makers and program-planners to
understand the outcomes that they should reasonably expect to
affect by targeting internalized stigma. For clinicians, it is important
to know the extent to which internalized stigma adversely influ-
ences therapeutic outcomes and recovery processes for people with
mental illness. Moreover, answering the question of whether
internalized stigma of mental illness is particularly prevalent
within certain populations is an important consideration for health
promotion and prevention strategies.
Method
Study selection
The search strategy included locating relevant articles by
searching several electronic databases, including PsychINFO,
PubMed, and Web of Science. Web of Science includes the Arts &
2152 J.D. Livingston, J.E. Boyd / Social Science & Medicine 71 (2010) 2150e2161

Humanities Citation Index (1975epresent), the Social Citation Initial search results 1
Index Expanded (1900epresent), and the Social Sciences Citation k = 3,127
Index (1956epresent). An inclusive search strategy that used broad
Titles excluded
keywords was purposely chosen in order to ensure a comprehen- k = 2,777
sive scan of the literature. In January 2010, the keywords ‘stigma’
AND ‘mental illness’ were entered into the databases, and English- Abstracts & full articles
reviewed 2
language titles were obtained. Additional titles were retrieved by k = 350
manually searching the references of all included full-text articles.
Publications not meeting inclusion criteria and
Selected stigma experts reviewed the reference list, but this process excluded k = 242
did not generate additional titles.
i. Not primary research k = 72
ii. Not focused on adults with mental illness k = 67
Inclusion criteria iii. No measure of internalized stigma k = 93
iv. No statistical relationship reported k = 9
v. Full-text article unavailable k = 1
An article was included for a full review if it met all of the Publications meeting
following criteria: (i) constituted primary research published in inclusion criteria
k = 108
a scholarly or professional journal, (ii) focused on the perspective of
adults diagnosed with a mental illness, (iii) included quantitative Publications identified
measures pertaining to internalized stigma or self-stigma and at by reference searching
k = 19
least one other variable (such as an outcome or demographic
variable), (iv) reported on the statistical relationship between the
two variables, (v) could be retrieved by contacting the author or Publications included in
systematic review
through university library services, and (vi) was written in English. k = 127
The aforementioned conceptualizations and definitions of inter-
Publications not meeting meta-analysis inclusion
nalized stigma were used to screen articles for inclusion. For criterion and excluded k = 82
purpose of this paper, ‘mental illness’ was defined as an Axis I
clinical disorder as specified by the Diagnostic and Statistical i. No included variable studied k = 8
ii. No established stigma measure used k = 42
Manual of Mental Disorders (American Psychiatric Association, iii. No r or t values reported k = 32
2000). Articles were excluded if their sample consisted of adults
Publications included in
diagnosed with substance-related disorders, but without any other
meta-analysis
comorbid Axis I mental illnesses. Articles were also excluded if they k = 45
were purely descriptive; that is, they did not examine associations
between internalized stigma and any other variable. The inclusion
1
criteria for the systematic review did not contain restrictions on Includes duplicates
2
publication date or methodological rigor. Excludes duplicates
Additional inclusion criteria were used for the meta-analyses. A Fig. 1. Search results and article selection procedures.
variable was selected for meta-analysis when the majority of
studies that had examined a particular variable indicated it was references for titles that appeared to be about internalized stigma,
significantly related with internalized stigma (see Table 3). The which generated an additional 19 articles that were included in the
rationale for this criterion was that small, non-significant effect review. In total, 127 articles were included in the systematic review
sizes were expected for variables that had not demonstrated and 45 articles were included in the meta-analyses.
a significant relationship with internalized stigma in the majority of
studies. This assumption was confirmed by analyzing one variable
(age) that failed to meet this meta-analysis inclusion criteria, with Data extraction
the results indicating a small, non-significant effect size with
internalized stigma (r ¼ .004, p > .05). Another rationale for this Data on the following variables were coded and entered into
meta-analysis inclusion criterion was that non-significant correla- a spreadsheet: author, publication date, country, sample size, study
tions were often mentioned in the articles without an indication of design, utilization of stigma intervention, length of follow-up period,
their statistical value. Therefore, large amounts of missing data living arrangement, gender, psychiatric diagnoses, average age in
were expected for these variables. An article was selected for years, marital status, employment status, average illness duration in
inclusion in the meta-analyses if it satisfied the following criteria: years, ethnicity, education, internalized stigma measures, and main
(i) measured internalized stigma using an established instrument, findings.
(ii) contained a variable that was selected for meta-analysis on the Several studies used multiple subscales or measures of a single
basis of the aforementioned criteria, and (iii) reported the statistical variable (e.g., internalized stigma, quality of life), which often
relationship using correlation coefficients or t-test values. resulted in mixed findings regarding the relationship (e.g., signifi-
As illustrated in Fig. 1, the initial search generated 3127 titles cance, strength, direction) between the two variables. In such cases,
that were reviewed by one author for relevance. The large number data on the variable’s total score was used. This approach is consis-
of titles that were initially retrieved was a consequence of the tent with that which was employed in a meta-analysis of HIV
comprehensive, inclusive search strategy. A total of 2777 titles were internalized stigma (Logie & Gadalla, 2009). If a total score was not
excluded, primarily because they did not constitute primary reported, then the findings relating to the dominant subscale or
research or they pertained to other forms of stigma (e.g., social measure e that is, the one that most closely resembled the construct
stigma). The abstracts and full-text articles of the remaining 350 and contained the most items e were used. A dominant subscale or
titles were thoroughly reviewed and 242 titles were excluded for measure of a particular variable could not be determined in eight
failing to meet one of the aforementioned inclusion criteria. The studies with mixed findings. In these cases, any subscale that was
remaining 108 titles were hand inspected by reading the full-text significantly related to the variable of interest was selected for
articles to locate other relevant articles and by reviewing the inclusion in the analysis. For example, a study by Griffiths,
 J.D. Livingston, J.E. Boyd / Social Science & Medicine 71 (2010) 2150e2161 2153

Christensen, and Jorm (2008) found that gender was significantly The analyses in Table 4a and b indicates that the test of homoge-
related to the ‘personal stigma’ subscale of the Depression Stigma neity is significant for several variables. For this reason, and because
Scale, but was not related to the ‘perceived stigma’ subscale. Since the methodological characteristics of the included studies are vari-
neither of these subscales can be considered dominant, the personal able enough to have potentially influenced the results, the random
stigma subscale was selected for analysis. This approach ensured effects model was deemed to be more appropriate than the fixed
that a meta-analysis for a particular variable did not include multiple effect model (Borenstein, Hedges, Higgins, & Rothstein, 2009). The
effect sizes from a single study, which would violate the assumption random effects model is appropriate for heterogeneous effect size
of independent effect sizes (Quintana & Minami, 2006). distributions, since it assumes that the variability among the study-
level effect sizes results from both sampling error and between-study
variability (Berkeljon & Baldwin, 2009). One advantage of using
Data analysis a random effects model is that, unlike the fixed effects model,
statistical inferences may be made about the population of studies
The first step of the analysis involved selecting variables that were beyond those that are included in the meta-analysis (Berkeljon &
commonly assessed across the 127 included studies. For each variable Baldwin, 2009; Hedges & Vevea, 1998). Therefore, random effect
that was selected, descriptive analyses were performed to examine sizes were calculated for all of the variables.
the proportion of studies that detected a relationship between
internalized stigma and another variable at a .05 significance level. Results
Next, the direction (positive or negative) of each statistically signifi-
cant relationship was ascertained. Dummy variables, as are indicated Research characteristics
on Table 3, were used to determine the direction of a relationship;
however they were not used to ascertain the existence of a significant The reported characteristics of the 127 studies included in the
relationship. The meta-analysis inclusion criteria were satisfied by 45 review and the 45 studies used in the meta-analysis are outlined in
studies. Data were extracted and entered into the Comprehensive Table 1. Additional detail about the studies, including the outcome
Meta-analysis Version 2 software program for calculation of effect measures that were used, can be found in Supplementary Tables A
sizes for each variable (http://www.meta-analysis.com). Effect sizes and B. The description of study characteristics (below) concentrates
are an indication of the strength and magnitude of the relationship on the 45 meta-analysis studies.
between the variable of interest and internalized stigma (Berkeljon &
Baldwin, 2009). Since the purpose of the present study was to
Table 1
investigate the relationship between two variables, the most Research characteristics of the 127 studies included in the review and the 45 studies
appropriate effect size statistic was the correlation coefficient included in the meta-analysis.
(Quintana & Minami, 2006).
Characteristic All studies (k ¼ 127) Meta-analysis
Two separate analyses were performed on the variables that studies (k ¼ 45)
were included in the meta-analysis. For the first meta-analyses,
k Valid % k Valid %
effect sizes were calculated based on observed, or uncorrected,
Publication date
correlation coefficients. The second set of meta-analyses was per-
Pre 2000 13 10.2 1 2.2
formed after correcting for attenuation (Muchinsky, 1996). Consis- 2000 or later 114 89.8 44 97.8
tent with the suggestion by Hedges and Olkin (1985), study-level
Study design
effect sizes were individually adjusted to account for measurement Crossesectional 105 82.7 39 86.7
error (internal consistency) in both the predictor and dependent Longitudinal 22 17.3 6 13.3
variables. When information was available, coefficients of internal
Stigma intervention
consistency were taken directly from the included articles. If internal Yes 6 4.7 2 4.4
consistency was not reported in the article, then the values were No 121 95.3 43 95.6
obtained from another publication or, alternatively, by averaging
Region of study
reliability coefficients for measures of the same type across the North America 58 45.7 20 44.4
included studies (Mabe & West, 1982). Spearman’s (1910) equation Europe 42 33.1 15 33.3
for double correction was used to correct for measurement unreli- Asia 19 15.0 8 17.8
Middle East 7 5.5 1 2.2
ability. While corrected effect sizes are described in the results
South America 2 1.6 0 0
section, both corrected and uncorrected effect sizes are presented in Africa 2 1.6 1 2.2
Table 4a and b. Australia 1 .8 0 0
The homogeneity and heterogeneity of correlations across
Study sites
studies was assessed using the Q statistic and the I2 index, respec- Single country 123 96.9 43 95.6
tively. The Q statistic indicates if the variability of effect sizes around Multiple countries 4 3.1 2 4.4
the mean is equivalent to that which would be expected due to
Sample size
sampling error in the effect size distribution (Berkeljon & Baldwin, 1 to 100 53 41.7 23 51.1
2009; Quintana & Minami, 2006). A significant Q statistic indicates 101 to 250 46 36.2 19 42.2
that an effect size distribution is heterogeneous, which suggests 251 to 500 14 11.0 3 6.7
500 to 1000 10 7.9 0 0
that effect size variability may result from study characteristics.
1000þ 4 3.1 0 0
Whereas the Q test indicates the existence of heterogeneity in
a meta-analysis, I2 provides an index to quantify the degree of Internalized stigma measures
DDS 46 39.2 21 46.7
heterogeneity. As a test of heterogeneity, the I2 has several advan-
ISMI 15 11.8 10 22.2
tages over the Q test, such as its intuitive interpretation and wide SSMIS 9 7.1 8 17.8
range of applications (Higgins, Thompson, Deeks, & Altman, 2003; CESQ 6 4.7 6 13.3
Huedo-Medina, Sanchez-Meca, Marin-Martinez, & Botella, 2006). DSS 4 3.1 2 4.4
SSAS 4 3.1 1 2.2
Heterogeneity using this index may be interpreted as low (I2 ¼ 25),
Other/self developed 47 37.0 0 0
medium (I2 ¼ 50), or high (I2 ¼ 75) (Higgins et al., 2003).
2154 J.D. Livingston, J.E. Boyd / Social Science & Medicine 71 (2010) 2150e2161

Indicative of the growing interest in the topic of internalized
stigma for people living with mental illness, 97.8% (k ¼ 44) of the
studies were published in 2000 or later. Most of the studies used
a cross-sectional design (86.7%, k ¼ 39), with 13.3% (k ¼ 6) of
studies reporting longitudinal designs. Two (4.4%) studies provided
data on the effectiveness of interventions that are aimed at
addressing various aspects of internalized stigma; the remaining 43
(95.6%) studies used naturalistic designs. The median sample size of
the included studies was 100 participants, ranging from 20 to 500
participants. Half of the studies (51.1%, k ¼ 53) were carried out
with 100 or fewer participants.
The included English-language studies represent findings from
15 different countries. North American studies, mostly from the
United States (k ¼ 18), accounted for 44.4% (k ¼ 20) of the studies
included in the meta-analyses. Research conducted in European
countries accounted for 33.3% (k ¼ 15) of total studies, with slightly
more research generated from Sweden (k ¼ 5) than any other
European country. Eight (17.8%) of the included studies were from
Asian regions, primarily Hong Kong (k ¼ 6). One study was con-
ducted in the Middle East and one in Africa.
Sample characteristics
The reported characteristics of the study participants are outline
in Table 2. This section describes the participants included in the 45
meta-analysis studies. There was substantial variability between
the studies concerning the level of detail provided about their
sample characteristics. It is recognized that finer-level detail about
the sample characteristics is desirable; however, broad categories
were relied on in this study in order to maximize the number of
studies contributing to the data reported below. The average age of
participants across the studies was 41.1 years of age (SD ¼ 5.7). The
majority of participants were men (55.4%, N ¼ 3052). Nineteen
studies (42.2%) provided details on the ethnic diversity of their
samples, with participants representing 56.6% (N ¼ 1171) Caucasian
and 43.4% (N ¼ 900) non-Caucasian ethnic backgrounds.
In the nine (20.0%) studies that reported education level using
a secondary/high-school scheme, the majority of participants
(58.4%, N ¼ 1128) had at least a high school level of education. The
17 (37.8%) studies that reported the employment status of partici-
pants indicate that the majority (63.6%, N ¼ 1453) were unem-
ployed. Marital status was indicated in 46.7% (k ¼ 21) of the studies,
with most participants (70.7%, N ¼ 1724) reported to be unmarried.
While the majority of study participants (90.1%, N ¼ 4622, k ¼ 38)
lived in the community, 9.9% (N ¼ 509, k ¼ 9) of participants were
hospital inpatients. It is worth mentioning that not all of the
participants in the included studies were actively using mental
health services.
The psychiatric diagnoses of participants were indicated in 43
(95.6%) of the studies, with more than half of the participants
(54.3%, N ¼ 3221, k ¼ 36) diagnosed with a schizophrenia spectrum
disorder and 26.5% (N ¼ 1576, k ¼ 18) of the participants diagnosed
with a mood or anxiety disorder. For the 19 (42.2%) studies that
provide data on illness duration, the average time that participants
had been living with a mental illness or had been using mental
health services was 14.7 years (SD ¼ 6.7).
Internalized stigma measures
Measures of internalized stigma that were used in the included
studies are outlined in Table 1. This section describes the standard-
ized measures that were used in the 45 meta-analysis studies. The
numbers reported below include translated versions and slightly
modified versions of measures that were identified in the English-

Table 2
Sample characteristics of the 127 studies included in the review and the 45 studies included in the meta-analysis.

Characteristic All studies (k ¼ 127) Meta-analysis studies (k ¼ 45)

N Valid % (average) N Valid % (Average)

Gender k ¼ 117 k ¼ 44
Men 12,202 49.4 3052 55.4
Women 12,496 50.6 2454 44.6

Ethnicity k ¼ 55 k ¼ 19
Caucasian 7475 58.9 1171 56.6
Non-Caucasian 5210 41.1 900 43.4

Education k ¼ 31 k¼9
Less than high school 3074 35.1 803 41.6
High school or more 5681 64.9 1128 58.4

Employment k ¼ 42 k ¼ 17
Employed 2937 38.1 831 36.4
Unemployed 4763 61.9 1453 63.6

Marital status k ¼ 52 k ¼ 21
Married 3339 28.5 714 29.3
Not married 8392 71.5 1724 70.7

Psychiatric diagnoses k ¼ 111 k ¼ 43

Schizophrenia spectrum 9284 38.7 3221 54.3
Mood or anxiety 11,484 47.8 1576 26.5
Comorbid substance use 1866 7.8 358 6.0
Other 1366 5.7 781 13.2

Living arrangement k ¼ 113 k ¼ 40

Inpatient setting 3008 11.6 509 9.9
Community setting 22,844 88.4 4622 90.1

Average age in years k ¼ 108 k ¼ 43

22,232 41.4 yrs (SD 7.0) 5466 41.1 yrs (SD 5.7)

Average illness duration in years k ¼ 40 k ¼ 19

7136 13.6 yrs (SD 5.9) 2331 14.7 (SD 6.7)
 J.D. Livingston, J.E. Boyd / Social Science & Medicine 71 (2010) 2150e2161
language articles. Further detail about these measures may be found
in a recently published narrative review (Brohan et al., 2010).
The most frequently used internalized stigma measure was the
DevaluationeDiscrimination Scale (DDS) (Link,1987; Link, Mirotznik,
& Cullen, 1991), which was used in 46.7% (k ¼ 21) of the included
studies. It is also the oldest measure of internalized stigma for persons
with mental illness. The DDS is a 12-item measure that assesses the
extent to which respondents believe that people with mental illness
will be devalued or discriminated against. Several of the included
studies used modified versions of the DDS, including an 8-item scale
(Link, Castille, & Stuber, 2008). Across the studies that used the DDS,
the average coefficient for internal consistency was a ¼ .83.
The second most commonly used measure was the Internalized
Stigma of Mental Illness scale (ISMI) (Ritsher [Boyd], Otilingam, &
Grajales, 2003), which was used by 22.2% (k ¼ 10) of the included
studies. The ISMI is a 29-item questionnaire that assesses subjective
experiences of stigma using a total score and five subscale scores,
including alienation, stereotype endorsement, discrimination expe-
riences, social withdrawal, and stigma resistance. There are
numerous foreign-language versions of the ISMI, and numerous
versions pertaining to specific psychiatric and non-psychiatric
conditions. Although all the articles that used the ISMI that were
included in the present review were published in English, the
following language versions were used in collecting data from
participants of the included studies: Yoruba (Adewuya et al., 2009),
Chinese (Ho, Chiu, Lo, & Yiu, 2010), German (Sibitz, Unger,
Woppmann, Zidek, & Amering, 2009), and Hebrew (Werner, Aviv, &
Barak, 2008). The average coefficient for internal consistency on
the ISMI within the included studies was a ¼ .85.
The Self-Stigma of Mental Illness Scale (SSMIS) (Corrigan et al.,
2006) was used in 17.8% (k ¼ 8) of the studies. The SSMIS
contains 40 items and includes four subscales, including stereotype
awareness, stereotype agreement, stereotype self-concurrence,
and self-esteem decrement. A Chinese version of the SSMIS has
been developed and reported in several English-language articles
(Fung, Tsang, Corrigan, Lam, & Cheung, 2007). On average, studies
that used the SSMIS reported an internal consistency coefficient
of a ¼ .84.
Six (13.3%) studies measured internalized stigma using the
Consumer Experiences of Stigma Questionnaire (CESQ) (Dickerson,
Sommerville, Origoni, Ringel, & Parente, 2002; Wahl, 1999). The
CESQ has 21 items and 2 subscales that assess the degree to which
an individual has perceived negative social reactions on the basis of
their mental illness in the past month. The subjective processes
that are measured by the CESQ are encapsulated by the concept of
internalized stigma as defined by the present study. Across the
included studies, the average coefficient for internal consistency for
the CESQ was a ¼ .78.
The Depression Stigma Scale (DSS) (Kanter, Rusch, & Brondino,
2008) was used in two studies. The DSS measures the stigma of
depression using 32 items and five subscales, including general self-
stigma, secrecy, public stigma, treatment stigma, and stigmatizing
experiences. The average coefficient for internal consistency for the
DSS was a ¼ .94. The Taiwanese Self-Stigma Assessment Scale
(SASS) (Yen, Chen, Lee, Tang, Ko, et al., 2005; Yen, Chen, Lee, Tang,
Yen, et al., 2005) was used in one study. The Taiwanese-SASS
includes 8 items that measure internalized stigma in Taiwanese
populations with mental illness. The one study in the meta-analysis
that used the SSAS reported a Cronbach’s a of .80 (Yen, Chen, et al.,
2009; Yen, Lee, et al., 2009).
Correlates of internalized stigma
Tables 3 and 4 provide an overview of the relationship between
internalized stigma (as defined above) and other variables that
2155
were commonly studied. The sections below begin with a descrip-
tive analysis of all the studies that were included in the systematic
review, which is then followed by the results of independent meta-
analyses that were performed on a subset of the studies.
Sociodemographic variables
As shown in Table 3, none of the sociodemographic variables e
including, gender, age, education, employment, marital status,
income, and ethnicity e have, within the body of included studies,
demonstrated consistently significant relationships with internal-
ized stigma for people with mental illness. For example, the asso-
ciation between gender and internalized stigma was evaluated in
38 (29.9%) studies, with non-significance (p > .05) established in
81.6% (k ¼ 31) of those studies. Age was the sociodemographic
variable with the highest number of studies that had significant
findings (31.4%, k ¼ 11); however, the direction of the relationship
was mixed in the studies, with higher levels of internalized stigma
associated with being older in 36.4% (k ¼ 4) of the studies and being
younger in 63.6% (k ¼ 7) of the studies. Because none of the soci-
odemographic variables was significantly related to internalized
stigma in the majority of studies, they were not included in the
meta-analyses. Overall, the findings suggest that sociodemographic
variables are neither consistently nor strongly correlated with
levels of internalized stigma.
Psychosocial variables
All of the psychosocial variables included in this review e
including hope, self-esteem, empowerment/mastery, self-efficacy,
quality of life, and social support/integration e were significantly
associated with internalized stigma in the majority of studies,
ranging from 58% to 100%, within which they were examined (see
Table 3). For example, self-esteem had been examined in 34 (26.8%)
of the included studies, and was significantly associated with
internalized stigma in 30 (88.2%) of those studies. In addition, the
direction of these relationships was consistently negative in all of
the studies with significant findings. This consistent pattern indi-
cates that internalized stigma is negatively associated with a range
of psychosocial variables.
An independent meta-analysis was performed on each of the
psychosocial variables. The results of each relationship are pre-
sented in Table 4a and b according to the strength of their effect sizes.
High levels of internalized stigma were associated with hopeless-
ness (r ¼ .58, p < .001), poorer self-esteem (r ¼ .55, p < .001),
lowered empowerment/mastery (r ¼ .52, p < .001), reduced self-
efficacy (r ¼ .54, p < .001), decreased quality of life (r ¼ .47,
p < .001), and weakened social support/integration (r ¼ .28,
p < .05). The meta-analyses confirm the strength and consistency of
findings within the included studies regarding the relationship
between internalized stigma and these psychosocial variables.
Psychiatric variables
Findings concerning the relationship between internalized
stigma and a range of psychiatric variables e including psychiatric
symptom severity, psychiatric diagnosis, psychiatric hospitaliza-
tions, illness duration, insight, treatment adherence, treatment
setting, functioning, and medication side effects e were mixed. The
relationship between psychiatric symptom severity and internalized
stigma was examined in 47.2% (k ¼ 60) studies, making it the most
frequently studied relationship in this body of research literature.
Symptom severity had statistically significant, positive associations
with internalized stigma in 50 (83.3%) studies, and there were no
studies that found a statistically significant negative relationship.
Treatment adherence was examined in eleven (8.7%) studies, with
63.6% (k ¼ 7) of those studies demonstrating a significant, negative
correlation with internalized stigma. As indicated in Table 3, none of
2156 J.D. Livingston, J.E. Boyd / Social Science & Medicine 71 (2010) 2150e2161

Table 3
Relationship between sociodemographic, psychosocial, and psychiatric variables with internalized stigma (includes 127 studies).

Variables A. B. C. D. E.

Number of Non-significant Significant Positive Negative

studies (k ¼ 127) relationship relationship relationship relationship
(p > .05) (p < .05) (p < .05) (p < .05)

k % k % k % k % k %
Sociodemographic 47 37.0
Gender (1) 38 29.9 31 81.6 7 18.4 4 57.1 3 42.9
Age 35 27.6 24 68.6 11 31.4 4 36.4 7 63.6
Education 27 21.3 22 81.5 5 18.5 1 20.0 4 80.0
Employment (2) 14 11.0 10 71.4 4 28.6 0 .0 4 100.0
Marital status (3) 11 8.7 9 81.8 2 18.2 1 50.0 1 50.0
Income 10 7.9 8 80.0 2 20.0 0 .0 2 100.0
Ethnicity (4) 9 7.1 5 55.6 4 44.4 4 100.0 0 .0

Psychosocial 86 67.7
Self-esteem 34 26.8 4 11.8 30 88.2 0 .0 30 100.0
Quality of life 24 18.9 1 4.2 23 95.8 0 .0 23 100.0
Social support 12 9.4 5 41.7 7 58.3 0 .0 7 100.0
Empowerment 12 9.4 1 8.3 11 91.7 0 .0 11 100.0
Self-efficacy 8 6.3 0 .0 8 100.0 0 .0 8 100.0
Hope 5 3.9 0 .0 5 100.0 0 .0 5 100.0

Psychiatric 99 78.0
Symptom severity 60 47.2 10 16.7 50 83.3 50 100.0 0 .0
Diagnosis (5) 25 19.7 15 60.0 10 40.0 3 75.0 1 25.0
Illness duration 14 11.0 9 64.3 5 35.7 1 20.0 4 80.0
Hospitalizations 12 9.4 7 58.3 5 41.7 4 80.0 1 20.0
Insight 12 9.4 10 83.3 2 16.7 1 50.0 1 50.0
Treatment adherence 11 8.7 4 36.4 7 63.6 0 .0 7 100.0
Treatment setting (6) 10 7.9 7 70.0 3 30.0 2 66.7 1 33.3
Functioning 8 6.3 4 50.0 4 50.0 0 .0 4 100.0
Medication side effects 2 1.6 2 100.0 0 .0 na Na na na

(1) Columns D & E: 1 ¼ Men.

(2) Columns D & E: 1 ¼ Employed.
(3) Columns D & E: 1 ¼ Married.
(4) Columns D & E: 1 ¼ Non-Caucasian.
(5) Columns D & E: 1 ¼ Schizophrenia spectrum.
(6) Columns D & E: 1 ¼ Hospital inpatient.

the other psychiatric variables were significantly related with
internalized stigma in the majority of studies.
Meta-analyses confirmed the two main findings described
above: that internalized stigma was moderately correlated with
symptom severity (r ¼ .41, p < .001) and treatment adherence
(r ¼ .38, p < .001). Therefore, a higher level of internalized stigma
was associated with greater psychiatric symptom severity and
poorer treatment adherence.
Longitudinal findings
Longitudinal research designs were employed in 22 (17.3%) of the
studies, with six of these studies included in the meta-analyses. The

Table 4
Meta-analysis of the correlations between internalized stigma and select variables for people with mental illness (includes 45 studies).

Factor Number of studies Number of participants Random effect size (95% CI) Homogeneity index, Q Between-study variability, I2
a. Corrected for attenuation
Hope*** 4 390 .58 (.67,.48) 5.77 47.99
Self-esteem*** 19 2366 .55 (.62,.46) 129.42*** 86.09
Empowerment*** 7 764 .52 (.63,.39) 30.98*** 80.63
Self-efficacy*** 7 698 .54 (.72,.29) 94.98*** 93.68
Quality of life*** 13 1583 .47 (.56,.36) 79.54*** 84.91
Symptom severity*** 22 2453 .41 (.33, .49) 116.84*** 82.03
Treatment adherence*** 7 949 .38 (.47,.28) 15.97** 64.43
Social support* 3 306 .28 (.50,.03) 10.08** 80.15

b. Not corrected for attenuation

Hope *** 4 390 .51 (.58,.43) 2.30 .00
Self-esteem *** 19 2366 .46 (.53,.39) 81.35** 77.87
Empowerment *** 7 764 .44 (.53,.33) 17.12* 64.95
Self-efficacy *** 7 698 .43 (.57,.27) 36.62** 83.62
Quality of life *** 13 1583 .38 (.47,.29) 48.89** 75.46
Symptom severity *** 22 2453 .34 (.27, .41) 76.87** 72.68
Treatment adherence *** 7 949 .31 (.39,.23) 10.46 42.63
Social support * 3 306 .23 (.41,.03) 5.84 65.78

*p < .05.
**p < .01.
***p < .001.
 J.D. Livingston, J.E. Boyd / Social Science & Medicine 71 (2010) 2150e2161
median follow-up period across all the longitudinal studies was six
months, ranging from 1.25 months to 24 months. These studies
attempted to address questions such as: To what extent is internalized
stigma dynamic (i.e., changeable) or static (i.e., unchangeable)?
Which outcomes does internalized stigma predict? Which variables
predict internalized stigma?
Regarding the first question, only two of the longitudinal studies
included in this review explicitly report significant changes in
internalized stigma over time e both following an intervention.
Griffiths, Christensen, Jorm, Evans, and Groves (2004) found small
but significant reductions in personal stigma following an internet-
based intervention for people with depression. MacInnes and Lewis
(2008) also detected a significant reduction in self-stigma following
the implementation of a structured, group-based, cognitive thera-
peutic intervention. While elevated levels of internalized stigma
might be expected subsequent to initial illness onset or diagnosis,
or after discrimination experiences, none of the longitudinal
studies have featured this type of event during the follow-up
period.
In relation to the second question, four studies have found that
baseline levels of internalized stigma are negatively associated with
levels of self-esteem at follow-up. As well, single studies have found
that baseline levels of internalized stigma are associated with the
following variables at follow-up: increased service utilization,
greater unmet service needs, greater emotional discomfort, poorer
social adjustment, increased depressive symptom severity, and
poorer medication adherence. Regarding the question of which
baseline variables predicted elevated levels of internalized stigma at
follow-up, single studies have revealed the following variables:
increased perceptions of coercion, lower self-esteem, non-psychotic
disorder diagnosis, increased positive symptom severity, recent
onset of illness combined with level of social support, and shame-
related negative associations of mental illness.
Discussion
The systematic review uncovered a large body of research that has
examined associations between internalized stigma and other soci-
odemographic, psychosocial, and psychiatric variables. The results
from 127 studies produced interesting findings in each of these areas,
including a relatively small set of results from longitudinal studies.
Regarding sociodemographic variables, the lack of consistency across
disparate studies indicates that people with a wide range of charac-
teristics, who also have a mental illness, are susceptible to internal-
ized stigma. Regarding psychosocial variables, the review uncovered
a striking and robust negative relationship between internalized
stigma and a range of variables, with the meta-analyses revealing
significant correlation coefficients that range from .28 to .58. This
analysis indicates that a higher level of internalized stigma is asso-
ciated with lower levels of hope, empowerment, self-esteem, self-
efficacy, quality of life, and social support. Regarding psychiatric
variables, the review indicates that internalized stigma is positively
associated with psychiatric symptom severity and is negatively
associated with treatment adherence.
Focusing on the body of longitudinal studies, the present review
offered preliminary evidence to suggest that a high level of stigma
has detrimental effects on a wide range of outcomes, with self-
esteem being the most widely studied. The review of longitudinal
studies also offers an early glimpse at several variables (e.g., coer-
cion, self-esteem, positive symptoms of psychosis) that may, with
additional confirmatory evidence, serve as predictors of internal-
ized stigma over time. Importantly, two studies included in this
review have demonstrated that anti-stigma interventions are
associated with reductions in internalized stigma. Finding effective
ways to assist people with mental illness manage and cope with the
2157
effects of internalized stigma is important, and preliminary
evidence suggests that it can be done (Calmes et al., 2009; Griffiths
et al., 2004; Knight, Wykes, & Hayward, 2006; MacInnes & Lewis,
2008). This evidence is good news, given earlier disappointments
(Link, Struening, Neese-Todd, Asmussen, & Phelan, 2002).
The results of this review offer little support for directing inter-
nalized stigma-reduction strategies toward certain target pop-
ulations on the basis of sociodemographic characteristics, since
consistent patterns regarding statistical relationships were not
detected. Many of the studies were unique and not directly compa-
rable, which may have contributed to this finding. It is also probable
that this finding is an artifact of methodological limitations of the
included studies. Despite the fact that individuals exist on multiple,
intersecting axes of difference (e.g., race, gender, class, disability), the
internalized stigma research has primarily focused on how a single
factor or status influences and shapes peoples’ subjective experi-
ences. A major weakness of such a research approach is that it
excludes important social categories at the expense of over-simpli-
fying the complexity of a person’s lived experience. Furthermore,
studies that have considered multiple labels or social categories tend
to employ additive, rather than intersectional, analytic frameworks.
Limiting analyses to cumulative effects may miss important discov-
eries concerning the interlocking effects of multiple axes of oppres-
sion/domination on subjective experiences with internalized stigma.
The ideas embedded within the ‘intersectionality’ research paradigm
are well positioned to address this limitation (Burgess-Proctor, 2006;
Davis, 2008; Hancock, 2007; Hankivsky & Cormier, 2009).
This review found that psychosocial variables were robustly
(and moderately to strongly) associated with internalized stigma,
which is itself a psychosocial variable. One interpretation of this
finding is that, as a group, psychosocial variables are conceptually
intersecting and experientially intertwined. Indeed, authors
continue to struggle with creating meaningful operational defini-
tions of amorphous constructs such as internalized stigma, self-
esteem, quality of life, and empowerment. Internalized stigma is
a socially constructed concept that carries many different mean-
ings. Consequently, internalized stigma was measured in slightly
different ways across the studies that were reviewed. Variability in
the definition of stigma is, in part, a consequence of the funda-
mental epistemological and ontological differences of those who
seek to define the term. Link and Phelan (2001) pointed out that
conceptual variability also results from the complexity of the
phenomenon and the array of circumstances to which stigma has
been applied. Campbell and Deacon (2006) emphasized the
complexity of stigma by describing it as “a phenomenon rooted in
the individual’s psyche, yet constantly mediated by the material,
political, institutional and symbolic contexts” (p. 416).
Because of their nebulous nature, psychosocial variables some-
times overlap with one another, which is apparent in how inter-
nalized stigma has been defined and measured in the research
literature. Conceptual overlap is evident in leading definitions of
internalized stigma. For example, one definition conceptualizes
internalized stigma as “the loss of self-esteem and self-efficacy that
occurs when people internalize the public stigma” (Corrigan, Kerr
et al., 2005, p. 179). Measurement overlap is apparent in several
items and subscales that are contained within instruments that are
designed to measure internalized stigma. For example, the Self-
Stigma of Mental Illness Scale includes a subscale, ‘self-esteem
decrement’, that measures the degree to which “the person’s self-
esteem is diminished due to concurrence with the negative belief”
(Corrigan et al., 2006, p. 877). Perhaps the difficulty of compart-
mentalizing psychosocial variables into neat categories reflects the
messy and entangled nature of people’s lived experiences. Because
of conceptual and measurement issues in the literature, the find-
ings of this review can only suggest that these things called
2158 J.D. Livingston, J.E. Boyd / Social Science & Medicine 71 (2010) 2150e2161
‘psychosocial variables’ are related to “this thing called stigma”
(Manzo, 2004, p. 413). Greater attention needs to be paid to dis-
entangling the true nature of the relationship between internalized
stigma and the range of psychosocial variables that have been
identified in this review.
The results of the present study should be interpreted with
caution given the dearth of experimental, longitudinal research in
this area. It appears that what is now known about internalized
stigma has been predominately produced by naturalistic, cross-
sectional studies. Thus far, self-esteem is the only variable that has
demonstrated a robust relationship with internalized stigma using
both cross-sectional and longitudinal research designs. Indeed, the
lack of longitudinal research in this area of study is a significant
research gap that has inhibited the clinical relevance of findings
related to internalized stigma. Given the abundance of cross-
sectional research that has been published to date, it is advisable
that social scientists direct their resources and efforts to investi-
gating the relationship between internalized stigma and other
variables over time. This is particularly important as stigma-
reduction strategies for people with mental illness are being
developed and implemented without a solid empirical under-
standing of the longitudinal nature of internalized stigma.
Limitations
Several limitations need to be considered when interpreting the
findings of the present study. First, although a diverse set of
countries and populations were represented in the review, the
study did not include published research in languages other than
English. This restricts the cross-cultural generalizability of these
findings. Second, the review excluded qualitative research studies,
which means that internalized stigma in this study has been
approached and understood using a quantitative research para-
digm. A large body of qualitative research has made discoveries
about subjective experiences of internalized stigma for people with
mental illness that would not have been revealed using quantita-
tive methods (e.g., Collins, von Unger, & Armbrister, 2008; Yang
et al., 2010). New insights would likely emerge by integrating
these qualitative results using meta-synthesis or narrative review
methods. Third is the potential for null or negative findings to be
under-represented on account of publication bias, since researchers
and academic journals have traditionally minimized the impor-
tance of these findings (Quintana & Minami, 2006). The present
study did not include unpublished studies that met all the other
inclusion criteria, which may limit the accuracy of this synthesis of
extant findings on account of ‘file drawer’ effects. It is also possible
that the data extraction process introduced biases toward statisti-
cally significant findings; consequently, non-significant findings
may be underreported. Fourth, the present study was largely
exploratory, primarily based on observational studies, and focused
on bivariate correlation data. As such, we are not able to draw
causal inferences between internalized stigma and the other vari-
ables that were examined.
The fifth limitation is that the included studies measured
internalized stigma and other variables (e.g., quality of life, self-
esteem, symptom severity) using a variety of instruments. As
a result, conclusions drawn from the systematic review and meta-
analyses findings are limited by the fact that the studies may have
assessed somewhat different constructs, or different domains of
the same construct. While the meta-analysis inclusion criteria
attempted to address this potential problem, substantial variability
exists among the six established measures of internalized stigma.
For example, the use of a more narrow operational definition of
internalized stigma may have resulted in excluding the CESQ or the
DDS, which some researchers have asserted are measures of
different constructs (Brohan et al., 2010), from the meta-analysis.
Lastly, the degree to which the main findings of the current review
are a function of methodological variance was not ascertained. As
such, it is possible that internalized stigma appears to be more
highly related to psychosocial variables, in comparison with soci-
odemographic and psychiatric variables, because of similarities in
the way that they are assessed (i.e., self-report).
Conclusion
People who live with mental illness are susceptible to feeling as
though they are devalued and discredited members of society. The
present study has synthesized the research findings to date
regarding the correlates and consequences of internalized stigma
for people with mental illness. The most promising avenue for
future research inquiry appears to be investigating the longitudinal
relationship between internalized stigma and the range of
psychosocial variables that were identified in this review. This area
of research would benefit from further conceptual, theoretical, and
psychometric attention so that meaningful conclusions can be
drawn from the relationship between internalized stigma and
other psychosocial variables. Once a sufficient number of studies
has accumulated for a particular relationship (e.g., internalized
stigma and self-esteem), it is recommended that more detailed
analyses be performed to examine the role of moderator variables,
including those related to study design. Moreover, in addition to
ensuring basic study quality, researchers should consider the
following recommendations based on the findings and limitations
of previous studies: (a) measuring internalized stigma using
established measures in order to maximize the ability to draw
comparisons across studies, (b) using a longitudinal design with
repeated measures, (c) employing mixed method design that
incorporates both qualitative and quantitative components, and (d)
adopting an intersectional approach to understand the influence of
multiple social categories on experiences of internalized stigma.
Building a stronger longitudinal research foundation would
improve the potential for identifying people who are at risk for
developing a high level of internalized stigma. As well, additional
high-quality, longitudinal research is urgently needed in order to
inform the development of effective, evidence-based clinical
strategies for addressing the internalized stigma of mental illness.
Acknowledgements
We are grateful for the valuable feedback on an early draft of this
manuscript that was kindly provided by Dr. Steven P. Hinshaw. We
would also like to thank the anonymous reviewers of Social Science
& Medicine for their thoughtful comments.
Appendix. Supplementary material
Supplementary data related to this article can be found online,
at doi:10.1016/j.socscimed.2010.09.030
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