Evidence for the Effectiveness of Psychological Interventions for Internalized Stigma among Adults with Schizophrenia Spectrum Disorders: A Systematic Review and Meta-Analyses
Abstract
:1. Introduction
Aims
2. Materials and Methods
2.1. Search Strategy
2.2. Eligibility Criteria
2.3. Selection Process
2.4. Methodological Quality
2.5. Data Extraction and Management
2.6. Statistical Analysis
3. Results
3.1. Systematic Review
3.1.1. Study Selection
3.1.2. Quality Assessment
3.1.3. Study Characteristics
3.1.4. Characteristics of Interventions Used
3.1.5. Characteristics of Outcome Measures Used
3.1.6. Results of the Interventions
3.2. Meta-Analysis
3.2.1. Subgroup Analysis
Narrative Enhancement and Cognitive Therapy (NECT)
Group Psychoeducation
3.3. Publication Bias
3.4. NHRMC Evidence Statement Matrix
4. Discussion
Strength and Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Study | Country | Study Design | Setting | Diagnosis | Sample Size | Intervention | Intervention N | Type | Frequency | Duration | Control | Control N | Type | Frequency | Duration | Outcome Measures | Main Result | Significance and Test used |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Shin S. & Lukens E.P. 2002 [29] | USA | RCT | outpatient | Schizophrenia | 48 | Group Psychoeducation | 24 | group | total 10 sessions (90 min/session) | 10 weeks | Supportive Sessions | 24 | individual | total 10 sessions (45 min/session) | 10 weeks | • SDS • BPRS • FCOPES | EG > CG | SoS = 2049.35; F = 376.10; df = 1,45; p < 0.001 ANCOVA |
Aho-Mustonen K. et al. 2011 [30] | Finland | RCT | inpatient | Schizophrenia, Schizoaffective | 39 | Group Psychoeducation | 19 | group | total 8 sessions (45–60 min/session) | 8 weeks | TAU | 20 | NA | NA | NA | •PSQ • KASQ • SUMD • CRS • DAI-10 • BPRS • NOSIE-30 • BDI-II • RSE • 15D | CG > EG | p = 0.08 Cohen’s d = −0.59 Student’s t-tests |
Fung K.M.T 2011 [57] | China | RCT | outpatient | Schizophrenia | 66 | Self-Stigma Reduction Programme | 34 | group + individual | total 12group + 4 individual (2 group sessions/week) | NA | Newspaper reading | 32 | group + individual | total 12group + 4 individual (2 group sessions per week) | NA | • CSSMIS • PTCS • BPRS • GAF • CAQ-SPMI • SUMD • CGSS | EG > CG | F = 2.204; p = 0.096 Effect size = 0.096 Repeated measures ANOVA/ANCOVA with Bonferroni correction |
Uchino T. et al. 2012 [58] | Japan | NRCT | outpatient | Schizophrenia, Schizoaffective | 56 | Group Psychoeducation | 29 | group | total 6 sessions (1 session/week) | 6 weeks | TAU | 27 | NA | NA | NA | • SDS-J • KIDI • DAI-10 • BPIS • GAF | EG > CG | p < 0.01 Mann-Whitney U-test |
Yanos P.T. et al. 2012 [33] | USA | RCT | outpatient | Schizophrenia, Schizoaffective, BMD, MDD | 35 | NECT | 15 | group | (1 h/session 1 session/week) | 20 weeks | TAU | 20 | NA | NA | NA | • ISMI • BHS • RSES • CSC • QLS • PANSS • SUMD | EG = CG | F = 1.06; p = 0.312 Cohen’s d = 0.37 ANOVA |
Silverman M.J. et al. 2013 [42] | USA | pseudo-RCT | inpatient | MDD, BMD, Schizophrenia, Psychosis, Anxiety, PTSD | 78 | Music therapy (Mental Illness Stigma Educational Group Songwriting Session) | 29 | group | total 24 sessions (45 min/session ×1/week) | 6 months | Group No-Music Educational Mental Illness Stigma Talk-based Session (Active Control Group) Wait-list Control Group (rock and roll bingo) | 17 32 | group group | total 8 sessions (45 min/session) total 8 sessions (45 min/session) | 6 months 6 months | • SS | EG > WLCG EG = ACG | (df)F = (2,75)5.09; p = 0.008 ηp2 = 0.120 F test, Bonferroni inequality |
Roe D. et al. 2014 [48] | Israel | NRCT | NA | SMI | 119 | NECT | 63 | group | total 20 sessions (1 h/session ×1/week) | 6 months | TAU | 56 | NA | NA | NA | • ISMI • MANSA • ADHS • RSE | EG > CG | F = 7.81; p = 0.006 ηp2 = 0.06 ANOVA |
Russinova Z. et al. 2014 [52] | USA | RCT | NA | Schizophrenia spectrum disorder, BMD, MDD, Others | 82 | Antistigma Photovoice Program | 40 | group | total 10 sessions (90 min/session) | 10 weeks | Waiting List | 42 | NA | NA | NA | •ISMI •ACS •ES •GPSES •PGRS •CES-D | EG > CG | p = 0.03 Cohen’s d = 0.55 mixed-effects linear regression |
Morrison A.P. et al. 2016 [59] | England | RCT | outpatient | Schizophrenia spectrum disorder, Schizoaffective disorder, BMD with psychotic features, FEP, EIS | 27 | Cognitive Therapy | 14 | individual | total 12 sessions (1 h/session) | over a 4 month period | TAU | 13 | NA | NA | NA | • ISMI-R • SIMS • SS • QPR • BDI-7 • BHS • SIAS • SERS-S • ISS | EG = CG | F = 0.052; p = 0.822 Cohen’s d = 0.09 ANCOVA |
Ngoc T.N. et al. 2016 [55] | Vietnam | RCT | inpatient | Schizophrenia | 49 | Family Schizophrenia Psychoeducation Program (FSPP) | 26 | individual | total 3 sessions (1.5 h/session) | 1.5 week | TAU | 23 | NA | NA | NA | • STS • QLESQ • MCI • CS | EG > CG | F(1,45) = 6.67; p < 0.05 R2 = 0.13 ANCOVA |
Hansson L. et al. 2017 [34] | Sweden | RCT | mixed | SMI | 87 | NECT | 41 | group | total 20 session (1 h/session) | NA | Waiting List | 46 | NA | NA | NA | • SSMIS-SF • RSES • MANSA | EG > CG | 95% CI = 0.04–0.89; p = 0.013 Cohen’s d = 0.5 ANOVA |
Ivezić S.S. et al. 2017 [41] | Croatia | pseudo-RCT | outpatient | Schizophrenia | 80 | Group Psychoeducation | 40 | group | total 12 sessions | 12 weeks | Waiting List | 40 | NA | NA | NA | • ISMI • BUES • PDD | EG > CG | F/t = 8.18; p = 0.005 ηp2 = 0.097 sample t-test |
Lucksted A. et al. 2017 [51] | USA | RCT | outpatient | Schizophrenia, BMD, Recurrent major depressive, Schizotypal, Borderline personality, Other delusional or psychotic disorder | 253 | Ending Self- Stigma Psychoeducational intervention | 122 | group | total 9 sessions (90 min/session) | 9 weeks | TAU (minimally enhanced by a brochure about internalized stigma) | 131 | NA | NA | NA | • ISMI-29 • SSMIS • MARS • GSES • SOBI • BSI • ESS • BCI • R-BANS | EG > CG | df = 252; p = 0.131 Effect size = –0.139 repeated measures mixed model |
Wood L. et al. 2017 [53] | England | RCT | inpatient | Schizophrenia, Schizoaffective Schizophreniform, Delusional disorder, Psychotic disorder NOS, EIS | 30 | CBT | 15 | individual | total 1–2 sessions (2 h/session) | 2 weeks | Psychoeducation | 15 | individual | total 1–2 sessions (2 h/session) | 2 weeks | • ISMI-S • SS • SERS • QPR • BDI-PC • AMHP | EG = CG | F = 0.306; p = 0.585 Cohen’s d = −0.238 ANCOVA |
Li J. et al. 2018 [50] | China | RCT | outpatient | Schizophrenia | 327 | • SASD • Psycho-education • SST • CBT | 169 | individual | total 8 sessions (2 h/session) | 9 months | Face-to-face Interview | 158 | individual | NA | 9 months | • ISMI • DISC-12 • GAF • SQLS • SES • BPRS • PANSS-N | CG > EG | OR(95%CI) = −0.04(−0.14 to 0.06); p = 0.440 ICC = 0.1235 Linear Mixed Models |
Yilmaz E. and Kavak F. 2018 [44] | Turkey | NRCT | outpatient | Schizophrenia | 69 | Mindfulness-Based Psychoeducation | 34 | group | total of 12 sessions 2 days/week | 6 weeks | TAU | 35 | NA | NA | NA | • ISMI | EG > CG | p = 0.001 Mann–Whitney U = 98.000 Independent-samples t test |
Gaebel W. et al. 2019 [56] | Germany | RCT | mixed | Schizophrenia spectrum disorders, Depression | 462 | Psychoeducational Group Therapy + STEM + Booster session | 227 | group | total 12 sessions (8 + 3 + 1) | 4 to 11 weeks + 6w later booster | psychoeducational group therapy + booster session | 235 | group | total 12 sessions (11 + 1) | 4 to 11 weeks + 6w later booster | • ISMI • HAM-D • PANSS • CGI • GAF • KCS • WHO-QOL-BREF • BUES • RSES • SCL-27 | EG = CG | p = 0.83 d = 0.3 mixed models analyses and t tests |
Yanos P.T. et al. 2019 [54] | USA | RCT | mixed | Schizophrenia, Schizoaffective | 118 | NECT | 65 | group | total 20 sessions | 20 weeks | Supportive Group Therapy | 52 | group | total 20 session | 20 weeks | • ISMI • RSES • BHS • QLS • MSIF • PANSS • CSC • STAND | EG > CG | F = 2.19; df = 3347; p = 0.09 Effect Size = 0.25 (small-to-moderate) mixed-effects modeling, GPower3 |
Díaz-Mandado O. & Perianez J. A. 2020 [60] | Spain | RCT | outpatient | Schizophrenia, Schizotypal, Persistent delusional disorder, Schizoaffective, Other non organic psychotic disorders, BMD, Recurrent depressive disorder, OCD | 54 | “Coping Internalized Stigma Program” (PAREI) | 29 | group | total 8 sessions (2 h/session ×1/week) | 8 weeks | TAU | 25 | NA | NA | NA | • ISMI • PL • GI • RAS-41 • BPRS • SFS | EG > CG | F = 2.88; p = 0.1 ηp2= 0.06 ANOVA |
Drapalski A.L. et al. 2020 [61] | USA | RCT | outpatient | BMD, Schizophrenia, Schizoaffective, MDD with psychotic features | 216 | Ending Self-Stigma | 106 | group | total 9 session (75–90 min/session ×1/week) | 9 weeks | Health & Wellness Intervention | 110 | group | total 9 session (75–90 min/session ×1 session/week) | 9 weeks | • ISMI • SOBI • GSES • MARS • SSMIS | EG = CG | t = 0.72; p = 0.470 repeated-measures, mixed effects model |
Konsztowicz S. et al. 2020 [43] | Canada | pseudo-RCT | mixed | Schizophrenia, Schizoaffective, Other psychotic disorder, MDD with psychotic features, BMD with psychotic features, Unspecified schizophrenia spectrum and other psychotic disorder | 35 | Self-concept and Engagement in LiFe (SELF) | 18 | individual | 50 min/session ×1/week | average of 4.6 weeks | TAU | 17 | NA | NA | NA | • ISMI • MES • RSQ • SERS • CDS • Q-LES-Q-18 • STQ • CSQ | EG > CG | F = 1.23; df = (1, 31); p = 0.28 ηp2 = 0.04 ANCOVA |
Young D.K.W. et al. 2020 [45] | China | NRCT | outpatient | Depression, Schizophrenia, BMD, Anxiety, Others | 78 | Destigmatized Group Intervention | 36 | group | total 10 sessions (90 min/session ×1 session/week) | 10 weeks | TAU | 42 | NA | NA | NA | • ISMI • RAS • BDI | EG > CG | t(p) = −0.812(0.417); F(p) = 7.482(0.008) ηp2= 0.099 ANCOVA |
Alhadidi M. et al. 2022 [32] | Jordan | RCT | inpatient | Schizophrenia | 122 | Group Psychoeducation | 66 | group | total 7 sessions (45–60 min/session) | 3 weeks | TAU | 56 | NA | NA | NA | • ISMI-10 • KASQ • BIS | EG > CG | F = 13.29, p < 0.001 d = –0.8 Repeat Measure ANCOVA |
Çiftçi M.C. & Budak K.F. 2022 [47] | Turkey | NRCT | outpatient | Schizophrenia | 100 | CBT-based Psychoeducation Program | 50 | group | total of 8 sessions (45–60 min/session ×2/week) | 4 weeks | TAU | 50 | NA | NA | NA | • ISMI • FROGS | EG > CG | t = 2.672; p = 0.009 Effect Size = 0.8 power analysis, t test |
Erdoğan E. & Demir S. 2022 [49] | Turkey | RCT | outpatient | Schizophrenia | 39 | Solution-Focused Group Psychoeducation Program | 20 | group | total 6 sessions (90 min/session ×2/week) | 6 weeks | TAU | 19 | NA | NA | NA | • ISMI • RSES • SubRAS | EG > CG | p < 0.001 W = 0.810 Spearman’s correlation analysis, Kendall W coefficient (effect size) |
Hasan A.A & Alasmee N. 2022 [62] | Jordan | RCT | outpatient | Schizophrenia spectrum disorder | 278 | Self-Stigma Reduction Programme | 140 | individual | total 13 sessions (biweekly) | 26 weeks | TAU | 138 | NA | NA | NA | • ISMI • PANSS • PTCS • CGSS | EG > CG | F = 187.75; p < 0.001 Effect Size = 0.59 (large) ANOVA |
Shih C. et al. 2022 [46] | Taiwan | NRCT | inpatient | Schizophrenia | 70 | Against Stigma Program | 35 | group | 60 min/session ×1/week | 6 weeks | TAU | 35 | NA | NA | NA | • ISMI • RES | EG > CG | p = 0.012 Effect Size = 0.760 Generalized estimating equation |
Study | Quality of Study | Experimental Group | Control Group | Main Result | Internalized stigma | Stereotype Endorsement | Stigma Resistance | Insight | Empowerment | Recovery | Self-esteem | Anticipated Discrimination | Perceived Discrimination | Social Withdrawal | Readiness of Change | Participation | Stereotype Agreement | Self-concurrence | Awareness | Application | Disclosure | Knowledge about illness | Alienation | Internalised Shame | Hope | Engulfment | Social Functioning | Perception | Self-eficacy | Compliance | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Shin S. & Lukens E.P. 2002 [29] | II A randomised controlled trial | 60% | GP | SS | EG > CG | ↑*** | ✓*** | ||||||||||||||||||||||||
Aho-Mustonen K. et al., 2011 [30] | II A randomised controlled trial | 87% | GP | TAU | CG > EG | ↔ | ✓↔ | ✓↔ | ✓↔ | ||||||||||||||||||||||
Fung K.M.T., 2011 [57] | II A randomised controlled trial | 87% | SRP | NR | EG > CG | ↔ | ✓* | ✓* | ✓* | ✓↔ | ✓↔ | ||||||||||||||||||||
Uchino T. et al., 2012 [58] | III-2 A comparative study with concurrent controls: ▪ Non-randomised, experimental trial | 80% | GP | TAU | EG > CG | ↑** | ✓** | ||||||||||||||||||||||||
Yanos P.T. et al., 2012 [33] | II A randomised controlled trial | 100% | NECT | TAU | EG = CG | ↔ | ✓↔ | ✓↔ | ✓↔ | ||||||||||||||||||||||
Silverman M.J. et al., 2013 [42] | III-1 A pseudorandomised controlled trial | 87% | GMT | GE, WL | EG > WLCG EG = ACG | ↑** | ✓* | ✓* | |||||||||||||||||||||||
Roe D. et al., 2014 [48] | III-2 A comparative study with concurrent controls: ▪ Non-randomised, experimental trial | 80% | NECT | TAU | EG > CG | ↑** | ✓** | ✓* | ✓* | ||||||||||||||||||||||
Russinova Z. et al., 2014 [52] | II A randomised controlled trial | 93% | APP | WL | EG > CG | ↑* | ✓* | ✓** | |||||||||||||||||||||||
Morrison A.P. et al., 2016 [59] | II A randomised controlled trial | 87% | CT | TAU | EG = CG | ↔ | ✓** | ✓* | ✓* | ||||||||||||||||||||||
Ngoc T.N. et al. 2016 [55] | II A randomised controlled trial | 53% | FSPP | TAU | EG > CG | ↑* | ✓** | ||||||||||||||||||||||||
Hansson L. et al., 2017 [34] | II A randomised controlled trial | 87% | NECT | WL | EG > CG | ↑* | ✓** | ✓* | ✓* | ✓* | |||||||||||||||||||||
Ivezić S.S. et al., 2017 [41] | III-1 A pseudorandomised controlled trial | 93% | GP | WL | EG > CG | ↑** | ✓↔ | ||||||||||||||||||||||||
Lucksted A. et al., 2017 [51] | II A randomised controlled trial | 93% | ESS | TAU | EG > CG | ↔ | ✓* | ✓* | ✓** | ✓** | ✓* | ||||||||||||||||||||
Wood L. et al., 2017 [53] | II A randomised controlled trial | 93% | CBT | PE | EG = CG | ↔ | ✓* | ✓* | |||||||||||||||||||||||
Li J. et al., 2018 [50] | II A randomised controlled trial | 93% | SASD PE SST CBT | FTF | CG > EG | ↔ | ✓* | ||||||||||||||||||||||||
Yilmaz E. and Kavak F. 2018 [44] | III-2 A comparative study with concurrent controls: ▪ Non-randomised, experimental trial | 87% | MBP | TAU | EG > CG | ↑*** | ✓*** | ✓*** | ✓*** | ✓*** | |||||||||||||||||||||
Gaebel W. et al., 2019 [56] | II A randomised controlled trial | 87% | STEM | GP | EG = CG | ↔ | ✓↔ | ✓↔ | |||||||||||||||||||||||
Yanos P.T. et al., 2019 [54] | II A randomised controlled trial | 93% | NECT | SGT | EG > CG | ↔ | ✓↔ | ✓* | |||||||||||||||||||||||
Díaz-Mandado O. & Perianez J. A. 2020 [60] | II A randomised controlled trial | 87% | PAREI | TAU | EG > CG | ↔ | ✓↔ | ✓↔ | ✓* | ✓↔ | ✓** | ✓* | |||||||||||||||||||
Drapalski A.L. et al. 2020 [61] | II A randomised controlled trial | 87% | ESS | HW | EG = CG | ↔ | ✓↔ | ✓↔ | ✓↔ | ||||||||||||||||||||||
Konsztowicz S. et al. 2020 [43] | III-1 A pseudorandomised controlled trial | 87% | SELF | TAU | EG > CG | ↔ | ✓↔ | ✓↔ | ✓* | ||||||||||||||||||||||
Young D.K.W. et al. 2020 [45] | III-2 A comparative study with concurrent controls: ▪ Non-randomised, experimental trial | 87% | DGI | TAU | EG > CG | ↑** | ✓↔ | ✓* | ✓** | ✓** | |||||||||||||||||||||
Alhadidi M. et al. 2022 [32] | II A randomised controlled trial | 93% | GP | TAU | EG > CG | ↑*** | ✓*** | ✓NA | |||||||||||||||||||||||
Çiftçi M.C. & Budak K.F. 2022 [47] | III-2 A comparative study with concurrent controls: ▪ Non-randomised, experimental trial | 87% | CBPP | TAU | EG > CG | ↑** | ✓** | ✓* | ✓↔ | ✓** | |||||||||||||||||||||
Erdoğan E. & Demir S. 2022 [49] | II A randomised controlled trial | 100% | SFGPP | TAU | EG > CG | ↑*** | ✓*** | ✓*** | ✓** | ✓*** | ✓*** | ||||||||||||||||||||
Hasan A.A & Alasmee N. 2022 [62] | II A randomised controlled trial | 87% | SRP | TAU | EG > CG | ↑*** | ✓* | ✓*** | ✓*** | ||||||||||||||||||||||
Shih C. et al. 2022 [46] | III-2 A comparative study with concurrent controls: ▪ Non-randomised, experimental trial | 87% | ASP | TAU | EG > CG | ↑* | ✓*** |
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Jagan, S.; Mohd Daud, T.I.; Chia, L.C.; Saini, S.M.; Midin, M.; Eng-Teng, N.; Ratnasingam, S. Evidence for the Effectiveness of Psychological Interventions for Internalized Stigma among Adults with Schizophrenia Spectrum Disorders: A Systematic Review and Meta-Analyses. Int. J. Environ. Res. Public Health 2023, 20, 5570. https://doi.org/10.3390/ijerph20085570
Jagan S, Mohd Daud TI, Chia LC, Saini SM, Midin M, Eng-Teng N, Ratnasingam S. Evidence for the Effectiveness of Psychological Interventions for Internalized Stigma among Adults with Schizophrenia Spectrum Disorders: A Systematic Review and Meta-Analyses. International Journal of Environmental Research and Public Health. 2023; 20(8):5570. https://doi.org/10.3390/ijerph20085570
Chicago/Turabian StyleJagan, Shankar, Tuti Iryani Mohd Daud, Lip Choy Chia, Suriati Mohamed Saini, Marhani Midin, Ng Eng-Teng, and Selvasingam Ratnasingam. 2023. "Evidence for the Effectiveness of Psychological Interventions for Internalized Stigma among Adults with Schizophrenia Spectrum Disorders: A Systematic Review and Meta-Analyses" International Journal of Environmental Research and Public Health 20, no. 8: 5570. https://doi.org/10.3390/ijerph20085570