Internalized stigma of mental illness and depressive and psychotic symptoms in homeless veterans over 6 months

Internalized stigma of mental illness and depressive and psychotic symptoms in homeless veterans over 6 months

Psychiatry Research 240 (2016) 253–259 Contents lists available at ScienceDirect Psychiatry Research journal homepage: www.elsevier.com/locate/psych...

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Psychiatry Research 240 (2016) 253–259

Contents lists available at ScienceDirect

Psychiatry Research journal homepage: www.elsevier.com/locate/psychres

Internalized stigma of mental illness and depressive and psychotic symptoms in homeless veterans over 6 months Jennifer E. Boyd a,b,n, H'Sien Hayward a,c, Elena D. Bassett a, Rani Hoff d a

Mental Health Service, San Francisco VA Health Care System, San Francisco, CA, USA Department of Psychiatry, University of California San Francisco, San Francisco, CA, USA c Department of Clinical Psychology, California School of Professional Psychology, Alliant International University, San Francisco, CA, USA d Departments of Psychiatry and Epidemiology, VA North East Program Evaluation Center and Yale School of Medicine, New Haven, CT, USA b

art ic l e i nf o

a b s t r a c t

Article history: Received 12 April 2015 Received in revised form 8 February 2016 Accepted 15 April 2016

We investigated the relationship between internalized stigma of mental illness at baseline and depressive and psychotic symptoms 3 and 6 months later, controlling for baseline symptoms. Data on homeless veterans with severe mental illness (SMI) were provided by the Northeast Program Evaluation Center (NEPEC) Special Needs–Chronic Mental Illness (SN-CMI) study (Kasprow and Rosenheck, 2008). The study used the Internalized Stigma of Mental Illness (ISMI) scale to measure internalized stigma at baseline and the Symptom Checklist-90-R (SCL-90-R) to measure depressive and psychotic symptoms at baseline and 3 and 6 month follow-ups. Higher levels of internalized stigma were associated with greater levels of depressive and psychotic symptoms 3 and 6 months later, even controlling for symptoms at baseline. Alienation and Discrimination Experience were the subscales most strongly associated with symptoms. Exploratory analyses of individual items yielded further insight into characteristics of potentially successful interventions that could be studied. Overall, our findings show that homeless veterans with SMI experiencing higher levels of internalized stigma are likely to experience more depression and psychosis over time. This quasi-experimental study replicates and extends findings of other studies and has implications for future controlled research into the potential long-term effects of antistigma interventions on mental health recovery. Published by Elsevier Ireland Ltd.

Keywords: Internalized stigma of mental illness Veterans Depression Psychosis

1. Introduction Internalized stigma (also known as self-stigma) is the psychological point of impact of stigma in society, in which people with mental illness absorb the negative stereotypes, biases and assumptions about mental illness that are present in society, and apply them to themselves (Link et al., 1989; Corrigan and Watson, 2002). Internalized stigma has been associated, for example, with lower levels of hope, self-esteem, empowerment, treatment adherence, and recovery orientation, as well as higher levels of psychiatric symptoms (Livingston and Boyd, 2010; Drapalski et al., 2013; Boyd et al., 2014). People with mental illness are affected by internalized stigma in many countries around the world. Indeed, the internalized stigma of mental illness has been deemed relevant and studied productively in a wide variety of cultural settings across the globe, such as in Austria (Sibitz et al., 2011), Canada (Michalak et al., n Corresponding author at: Mental Health Service, San Francisco VA Health Care System, San Francisco, CA, USA. E-mail addresses: [email protected], [email protected] (J.E. Boyd).

http://dx.doi.org/10.1016/j.psychres.2016.04.035 0165-1781/Published by Elsevier Ireland Ltd.

2011), China (Mainland and Hong Kong) (Fung et al., 2011; Mak et al., 2015; Young and Ng, 2015), Croatia (Margetić et al., 2010). Ethiopia (Bifftu et al., 2014) Europe (multiple countries) (EvansLacko et al., 2012; Krajewski et al., 2013), France (Bouvet and Bouchoux, 2015), Germany (Uhlmann et al., 2014), India (James et al., in press), Iran (Ghanean et al., 2011), Israel (Mashiach-Eizenberg et al., 2013; Werner et al., 2008), Japan (Shimotsu et al., 2014), Nigeria (Adewuya et al., 2011; Temilola et al., 2014), Poland (Świtaj et al., 2014), Portugal (Oliveira et al., 2015), South Korea (Hwang et al., 2006; Kim and Jun, 2012), Spain (Pérez-Garín et al., 2015), Switzerland (Cavelti et al., 2012), Taiwan (Yen et al., 2005), Thailand (Wong-Anuchit et al., 2016), Turkey (Yılmaz and Okanlı, 2015), and others (reviewed in Boyd et al. (2014)). An early, small-scale internalized stigma study found that stigma was associated with lower self-esteem and increased depression symptoms 6 months after baseline (Ritsher [Boyd] and Phelan, 2004). This finding was replicated in another small study that found internalized stigma at baseline was associated with emotional discomfort 6 months later (Lysaker et al., 2007). A more recent study (Pyle et al., 2015), found an association between negative appraisals of unusual psychological experiences and depressive symptoms 6 months later, controlling for depression at

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baseline. These findings speak to the demoralization inherent in living with a stigmatized condition for a significant period of time (Dohrenwend, 1990; Dohrenwend et al., 1980). Alienation, or feeling devalued as a member of society, appears to be an aspect of internalized stigma that is particularly strongly associated with symptoms over time (Ritsher [Boyd] and Phelan, 2004; Lysaker et al., 2007). However, it is unclear which aspects of alienation are the most strongly associated with elevated symptoms. While studies have examined associations between internalized stigma and depressive symptoms, less is known about the association between stigma and psychotic symptoms over time. In addition to being associated with reduced morale (depression and self esteem) (Ritsher [Boyd] and Phelan, 2004), internalized stigma may also be associated with increased psychotic symptoms, and if these relationships persist over time, they would likely make recovery more difficult. People with psychotic symptoms are more likely to attract public stigma and its harmful effects as well (i.e., Crisp et al., 2000). We are aware of no longitudinal study that has found a significant association between internalized stigma and later psychotic symptoms, though one small study found a trend in that direction (Lysaker et al., 2007). Similarly, we are aware of no studies that explore the substantive aspects of internalized stigma that are most strongly associated with later psychotic symptoms. The present study involves a large nationwide sample of homeless veterans with severe mental illness (SMI) followed over multiple time points. Homeless veterans are a population subject to experiencing stigma and devaluation (Applewhite, 1997; Phelan et al., 1997). Our aim was to examine the relationship of internalized stigma and depressive and psychotic symptoms over time among people with SMI in this marginalized group. Our objective was to test whether internalized stigma at one time point was related to higher levels of depression and psychosis at later time points, controlling for the initial levels of depression and psychosis.

(assessed through the NEPEC assessment); (3) intention to remain in the geographic area for at least a year; and (4) willingness to participate in the follow-up interviews (Kasprow and Rosenheck, 2008). The definition of “homelessness” used in the study was if at the time of screening, the veteran had spent at least one day homeless (in a shelter for the homeless, outdoors, abandoned building, automobile, truck or boat) in the past 90 days (or the 90 days immediately prior to a psychiatric hospitalization), or if discharged on the day of the screening, would have no residence available. Veterans were identified and referred by their treating mental health providers to the site's Study Coordinator at time of inpatient discharge planning, or by community providers upon exit from a homeless shelter. A total of 926 veterans were admitted to the study programs (Kasprow and Rosenheck, 2008). Not all participants provided data at every time point. Twelve sites were included in the dataset provided by NEPEC. For the present study, participants provided data on the included measures at more than one time point. Moreover, although data were collected for 2 years, we only used the first 6 months in the present study due to substantial missing data in later follow-ups. Thus, a total of 777 veterans were included in our analyses. Demographics (Table 1) were typical of the population served by the facilities associated with these sites (Kasprow and Rosenheck, 2008). Participants were followed over time regardless of their level of participation in the interventions offered at the 12 sites. As described by Kasprow and Rosenheck (2008), not all sites offered the same interventions. Many sites offered Vet-to-Vet, which was intended to reduce isolation and increase hope (Resnick et al., 2004; Resnick and Rosenheck, 2008), and could have affected stigma levels. Sitelevel differences and participation in the Vet-to-Vet intervention were statistically controlled in the analyses. All participants provided informed consent in accordance with protocols approved by the relevant Institutional Review Board at each site. 2.2. Instruments

1.1. Hypotheses

1. Internalized stigma will be associated with increased depression scores at both 3 and 6 months after baseline, controlling for baseline levels. 2. Internalized stigma will be associated with increased psychosis scores at both 3 and 6 months after baseline, controlling for baseline levels. 3. Alienation will be the aspect of internalized stigma most strongly associated with depressive and psychotic symptoms over time. 4. Exploratory analyses at the item level will indicate substantive areas that might be addressed in future work.

2. Method 2.1. Participants Participants in the study were homeless veterans with severe mental illness (SMI) who provided data at baseline, 3-month, and 6-month follow-up data as part of a longitudinal study called the “Special Needs-Chronically Mentally Ill (SN-CMI) Program for Homeless Veterans Discharged from VA Inpatient Care,” which was directed by the North East Program Evaluation Center (NEPEC) (Kasprow and Rosenheck, 2008). To be included in that study, recruitment criteria included (1) an SMI diagnosis (assessed through chart review of participants’ VA medical record, and including schizophrenia, schizoaffective disorder, bipolar disorder); (2) recent homelessness or imminent risk of homelessness

2.2.1. Internalized stigma Internalized stigma was measured using the Internalized Stigma of Mental Illness (ISMI) scale (Ritsher [Boyd] et al., 2003). The ISMI contains 29 Likert items rated on a 4-point scale ranging from “strongly disagree” to “strongly agree.” The internal consistency reliability for the scale in this sample (N ¼ 717) was 0.92. The ISMI contains five subscales: Alienation, Stereotype Endorsement, Discrimination Experience, Social Withdrawal and Stigma Resistance. The alienation subscale (α ¼0.81, N ¼ 750) measures the subjective experience of being less than a full member of society, and contains six items. The Stereotype Endorsement subscale (α ¼0.77, N ¼743) contains seven items measuring the degree to which respondents agree with common stereotypes about people with mental illness. The Discrimination Experience subscale (α ¼ 0.78, Table 1 Sample characteristics at baseline. Characteristic

% or Mean (SD)

N

Male Age Years of Education White, not Hispanic Black, not Hispanic Hispanic, White Hispanic, Black American Indian/Native Alaskan Asian Pacific Islander Other

94.3 49.6(8.5) 12.9(1.8) 54.6 35.8 3.2 0.8 1.8 0.4 0.9 2.5

732 774 777 421 276 25 6 14 3 7 19

Note: Some Ns do not add up to 777 due to missing data.

J.E. Boyd et al. / Psychiatry Research 240 (2016) 253–259

N ¼749) is composed of five items intended to capture respondents’ perception of the way that they currently tend to be treated by others. The Social Withdrawal subscale (α ¼0.85, N ¼751) measures the degree to which participants withdraw from others on the basis of having a mental illness, and contains six items. The Stigma Resistance subscale (α ¼ 0.52, N ¼748) was intended to portray the experience of resisting or being unaffected by internalized stigma. The stigma resistance items also serve as a validity check because they are reverse-coded. 2.2.2. Depressive and psychotic symptoms Depressive and psychotic symptoms were measured using the Symptom Checklist-90-R (SCL-90-R) Depression subscale and Psychoticism subscales (Derogatis et al., 1973, 1976). The questionnaire asks participants to rate how distressed they were in the past month by 90 different symptoms. Response anchors range from 0 (“not at all”) to 4 (“extremely”). Depression items include, for example, “crying easily” and “feeling hopeless about the future”. There are a total of 13 items in the Depression subscale, and its internal consistency reliability in this sample was (α ¼0.93, N ¼772). Psychoticism items include, for example, “hearing voices that other people do not hear” and “the idea that someone else can control your thoughts.” There are a total of 10 items in the Psychoticism subscale, and its internal consistency reliability in our sample was (α ¼0.85, N ¼768). 2.3. Data collection Veterans’ clinical case managers collected data by interview every 3 months, in person whenever possible, and by telephone otherwise (Kasprow and Rosenheck, 2008). Each interview took between 1 and 1.5 h to complete, and participants were offered $10 for each interview. All data collection procedures including interviews were conducted by Special Needs Program clinical evaluators. The Special Needs Program staff members were under the direction of the national office at NEPEC, and fidelity to all study procedures was ensured by semi-annual staff trainings and structured ratings using a detailed scale developed specifically for this program. 2.4. Data analyses We tested the association between internalized stigma and later depressive and psychotic symptoms using linear regression, controlling for baseline levels of symptoms. We also included gender, age, education, ethnicity, site, and participation in the Vetto-Vet intervention as control variables. The first four variables adjusted for differences associated with demographics. The site variable controlled for differences in interventions available at

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different sites. The Vet-to-Vet variable controlled for exposure to a mutual support group that might have had an impact on reducing internalized stigma. The models were run again by subscale and by individual item. As the study was largely exploratory, we used po 0.05 as our significance threshold throughout.

3. Results Although symptom levels decreased over time, we found that internalized stigma at baseline was significantly associated with higher levels of symptoms at 3 and 6 months. Table 2 presents bivariate correlations of baseline internalized stigma with symptoms assessed at each time point. Table 3 presents results when controlling for baseline levels of depressive or psychotic symptoms. Internalized stigma at baseline was significantly associated with increased depressive symptoms at 3-month follow-up, controlling for depressive symptoms at baseline (β ¼0.19, R2 ¼ 0.25, N ¼485, p o0.001). Similarly, internalized stigma at baseline was significantly associated with elevated depressive symptoms at 6-month follow-up (β ¼0.18, R2 ¼ 0.28, N ¼ 413, p o0.001). Internalized stigma at baseline was also significantly associated with elevated psychotic symptoms at the 3-month follow-up (β ¼ 0.13, R2 ¼0.34, N ¼485, po 0.01), controlling for the level of psychotic symptoms at baseline. Furthermore, internalized stigma at baseline was significantly associated with increased psychotic symptoms at the 6-month follow-up (β ¼0.11, R2 ¼0.33, N ¼412, po 0.05), controlling for the level of psychotic symptoms at baseline. We analyzed each ISMI subscale in a separate model (Table 3). As predicted, the Alienation subscale was significantly associated with both increased depressive and psychotic symptoms at both 3 and 6 months. The Discrimination Experience subscale was also significantly associated with increased depressive and psychotic symptoms at both 3 and 6 months. Stigma Resistance was not associated with symptoms at either time point; and the other subscales, Stereotype Endorsement and Social Withdrawal, were associated with increased depressive symptoms at 3 and 6 months, and psychotic symptoms at 3 months. There were not any significant associations with these subscales and psychotic symptoms at 6 months, although there were trends in that direction. As can be seen in Table 4, we conducted exploratory item-level analyses, to identify the specific items that appeared to be driving the subscale-level findings. For Alienation, the item “Having a mental illness has spoiled my life” was associated with both types of symptoms at both time points. Four other Alienation items involving feeling out of place, ashamed, inferior, or not understandable, were also associated with increased depressive symptoms at both

Table 2 Bivariate correlations of baseline internalized stigma and symptoms assessed at each time point. Depressive symptoms Baseline Alienation Stereotype endorsement Discrimination experience Social withdrawal Stigma resistance Total score

***

0.57 0.30*** 0.38*** 0.54*** 0.17*** 0.52**

Psychotic symptoms 3-Month ***

0.38 0.26*** 0.27*** 0.35*** 0.14** 0.37**

6-Month ***

0.40 0.25*** 0.30*** 0.39*** 0.07 0.38**

Note: Due to reverse coding, higher numbers are in the direction of more stigma for all items. *

p o 0.05. po 0.01. *** p o 0.001. **

Baseline ***

0.53 0.43*** 0.45*** 0.56*** 0.15*** 0.56**

3-Month ***

0.37 0.35*** 0.34*** 0.38*** 0.13** 0.41**

6-Month 0.38*** 0.32*** 0.34*** 0.38*** 0.12* 0.40**

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Table 3 Associations of baseline internalized stigma and symptoms at 3 and 6 months. Predictor

Alienation Stereotype endorsement Discrimination experience Social withdrawal Stigma resistance Total score (29 items)

Depressive symptoms

Psychotic symptoms

3-Month beta weights (N)

6-Month beta weights (N)

3-Month beta weights (N)

6-Month beta weights (N)

0.18**(486) 0.15**(485)

0.18**(413) 0.13**(413)

0.10*(486) 0.14**(485)

0.11*(412) 0.09(412)

0.14**(487)

0.14**(415)

0.10*(487)

0.09*(414)

0.17**(486) 0.06(484) 0.19**(485)

0.20**(415)  0.02(412) 0.18*(413)

0.09*(486) 0.02(484) 0.13** (485)

0.09(414) 0.001(411) 0.11* (412)

Note: Each model controlled for the baseline level of depressive or psychotic symptoms, as well as gender, age, education, ethnicity, interview site, and participation in the Vet-to-Vet intervention. Sample sizes varied because of missing data. In each analysis, participants were included if they answered at least 70% of the items in the scale. Due to reverse coding, higher numbers are in the direction of more stigma for all items. ***p o 0.001. * **

p o 0.05. po 0.01.

time points. Three of these were also associated with psychotic symptoms at one of the two time points. For Discrimination Experience, the most robust item was “People discriminate against me because I have a mental illness,” which was associated with both depression and psychosis, followed by “Nobody would be interested in getting close to me because I have a mental illness,” which was associated with depressive, but not psychotic symptoms. None of the other Discrimination Experience items were associated with later symptoms. Also shown in Table 4, two other items from the Stereotype Endorsement subscale were significantly associated with both types of symptoms at both time points: “People with mental illness cannot live a good, rewarding life” and “I can’t contribute anything to society because I have a mental illness”. Several items in the Social Withdrawal subscale were associated with elevated depressive symptoms at 3 and 6 months including “I avoid getting close to people who don’t have a mental illness to avoid rejection” and “I don’t talk about myself much because I don’t want to burden others with my mental illness.” This item was also associated with psychotic symptoms at the 6-month follow-up. As expected given the lack of subscale-level associations, the Stigma Resistance items did not show a robust pattern of association with symptoms (except that “Living with a mental illness has made me a tough survivor” was associated with higher depressive symptoms at 6 months, and “I can have a good, fulfilling life, despite my mental illness” was associated with lower depressive symptoms at 3 months).

4. Discussion As expected, higher internalized stigma total scores were significantly associated with higher scores on both depression and psychosis at both 3 and 6 months after baseline. Thus, our first two hypotheses were confirmed. Our third hypothesis was that the Alienation subscale would be the subscale most robustly associated with later symptoms. As expected, the Alienation subscale was associated with both types of symptoms at both time points. However, Hypothesis 3 was only partially supported because Alienation was not clearly stronger than all the other subscales (Table 3). Like Alienation, the Discrimination Experience subscale was

also significantly associated with both types of symptoms at both time points. Social Withdrawal and Stereotype Endorsement were associated with increased depression at 3 and 6 months, but increased psychotic symptoms only at 3 months. Consistent with past research, the Stigma Resistance subscale behaved differently than the others and was not associated with either type of symptom at either time point (reviewed in Boyd et al. (2014)). These findings raise the question of which aspects of Alienation and Discrimination Experience are so powerful for adult homeless veterans with mental illness. Our fourth hypothesis was that exploratory analyses at the item level would shed some light on this question. For Alienation, the most robust item was “Having a mental illness has spoiled my life.” Of course, feeling that one's identity has been “spoiled” is the cardinal feature of stigma as conceptualized by Goffman in his pioneering work on the subject (Goffman, 1963). For Discrimination Experience, the most robust item was a general one: “People discriminate against me because I have a mental illness”. It bears further investigation whether the stress associated with experiencing discrimination could contribute to symptom exacerbation, and which types of discrimination are the most harmful in this regard. Moreover, it would be interesting to further investigate this question in a less marginalized group of people with SMI rather than homeless veterans. The Social Withdrawal item with the most robust association with symptoms was “I do not talk about myself much because I do not want to burden others with my mental illness”. This item goes beyond using withdrawal as a coping mechanism or as an expression of depression, to using it to prevent the discomfort of others. It is easy to imagine the negative effect that trying not to burden others would have on the development and maintenance of a strong, supportive, healthy relationship. Our exploratory analyses also revealed that two items from the Stereotype Endorsement subscale were statistically significantly associated with both types of symptoms at both time points: “People with mental illness cannot live a good, rewarding life” and “I can not contribute anything to society because I have a mental illness”. If individuals internalize these types of stereotypes about people with mental illness, they may lose hope for their future and give up on their goals, possibly contributing to worsened depression and psychotic symptoms. Overall, our findings show that homeless veterans with severe mental illness who are experiencing higher levels of internalized stigma are likely to feel detectably worse than those with lower levels of internalized stigma over time. Feeling alienated and experiencing discrimination are especially pertinent aspects of internalized stigma. Yanos et al. (2008) studied a possible mechanism by which internalized stigma could be associated with depression among people with schizophrenia spectrum disorders. They conducted path analyses of cross-sectional data and found results consistent with the hypothesis that “internalized stigma reduces a person's hope and self-esteem, leading to negative outcomes related to recovery, including depressive symptoms.” Regarding psychotic symptoms, they found that their data supported a model in which internalized stigma had a more indirect path to psychotic symptoms, through hope and self-esteem first, and then secondly through social avoidance, and/or avoidant coping. However, this finding regarding psychosis was tempered with the fact that an alternative model where psychosis was a predictor rather than an outcome also fit their data. Our study used longitudinal data, and our findings are consistent with their hypotheses that internalized stigma is related to symptoms of depression and psychosis. A more recent study by Sibitz et al. (2011) also used path analysis of cross-sectional data from people with schizophrenia spectrum disorders, and found that stigma had a direct path to depression, which in turn had a path to quality of life. Social network and empowerment were also included in the

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Table 4 Associations between internalized stigma items at baseline and symptoms at 3 and 6 months. Predictor (item)

Alienation I feel out of place in the world because I have a mental illness I am embarrassed or ashamed that I have a mental illness I feel inferior to others who don't have a mental illness I am disappointed in myself for having a mental illness Having a mental illness has spoiled my life People without mental illness could not possibly understand me

Stereotype Endorsement Mentally ill people tend to be violent Mentally ill people shouldn't get married People with mental illness cannot live a good, rewarding life People can tell that I have a mental illness by the way I look Because I have a mental illness, I need others to make most decisions for me I can't contribute anything to society because I have a mental illness Stereotypes about the mentally ill apply to me

Discrimination Experience People discriminate against me because I have a mental illness People often patronize me, or treat me like a child, just because I have a mental illness People ignore me or take me less seriously just because I have a mental illness Nobody would be interested in getting close to me because I have a mental illness Others think that I can't achieve much in life because I have a mental illness

Social Withdrawal I avoid getting close to people who don't have a mental illness to avoid rejection I don't socialize as much as I used to because my mental illness might make me look or behave “weird” I don't talk about myself much because I do not want to burden others with my mental illness Negative stereotypes about mental illness keep me isolated from the “normal” world Being around people who don't have a mental illness makes me feel out of place or inadequate I stay away from social situations in order to protect my family or friends from embarrassment

Stigma Resistance People with mental illness make important contributions to society I feel comfortable being seen in public with an obviously mentally ill person Living with mental illness has made me a tough survivor In general, I am able to live life the way I want to I can have a good, fulfilling life, despite my mental illness

Depressive symptoms

Psychoticism symptoms

3-Month beta weights (N)

6-Month beta weights (N)

3-Month beta weights (N)

6-Month beta weights (N)

0.13**(487) 0.11*(486) 0.09*(487) 0.09(487) 0.13**(481) 0.14**(484)

0.21***(415) 0.15**(415) 0.08**(414) 0.01(414) 0.13**(409) 0.10*(411)

0.05(487) 0.06(486) 0.05(487) 0.03(487) 0.10*(481) 0.11**(484)

0.15**(414) 0.11*(414) 0.03(413)  0.02(413) 0.10*(408) 0.04(410)

0.07(483) 0.04(481) 0.14**(482) 0.07(485) 0.07(484)

 0.01(413) 0.08(411) 0.12**(411) 0.07(413) 0.04(412)

0.09*(483) 0.06(481) 0.11**(482) 0.09*(485) 0.04(484)

 0.009(412) 0.05(410) 0.09*(410) 0.02(412) 0.03(411)

0.12**(486)

0.15**(414)

0.09*(486)

0.11*(413)

0.16***(484)

0.06(410)

0.12**(484)

0.06(409)

0.13**(487) 0.05(489)

0.11*(416) 0.06(416)

0.10*(487) 0.06(489)

0.11*(415) 0.03(415)

0.07(486)

0.09(414)

0.03(486)

0.04(413)

0.11*(485)

0.12**(413)

0.06(485)

0.04(412)

0.08(481)

0.08(411)

0.07(481)

0.08(410)

0.10*(486)

0.10*(416)

0.07(486)

0.02(415)

*

**

0.08 (483)

0.14 (413)

0.04(483)

0.07(412)

0.14**(485)

0.21***(414)

0.06(485)

0.12**(413)

0.14**(486)

0.11*(414)

0.06(486)

0.05(413)

**

*

0.10 (411)

0.10 (482)

0.03(410)

0.05(487)

**

0.14 (416)

0.03(487)

0.06(415)

0.04(487)

0.03(414)

0.03(487)

0.02(413)

0.02(484)

 0.05(412)

0.01(484)

 0.04(411)

 0.04(485) 0.03(485) 0.09*(489)

 0.10*(412) 0.02(415) 0.03(415)

 0.05(485)  0.01(485) 0.05(489)

 0.07(411) 0.04(414) 0.04(414)

0.15 (482)

*

Note: Each model controlled for the baseline level of depressive or psychotic symptoms, as well as gender, age, education, ethnicity, interview site, and participation in the Vet-to-Vet intervention. Sample sizes varied because of missing data. In each analysis, participants were included if they answered at least 70% of the items in the scale. Due to reverse coding, higher numbers are in the direction of more stigma for all items. *

p o 0.05. po 0.01. *** p o 0.001. **

model but not psychotic symptoms (see Sibitz et al., 2011). These two studies also highlighted potential recovery-related outcomes that could be connected to the relationship between stigma and symptoms, namely quality of life and social avoidance. In addition to being compatible with the above studies regarding people with SMI, our results regarding the connection between stigma and depression using longitudinal data are also

consistent with a new study of people at risk for psychosis but not diagnosed with SMI. This longitudinal study conducted by Pyle et al. (2015) found that internalized stigma “contributed to depression at 6-month followup when controlling for baseline depression.” (p. 137). The aspect of internalized stigma that produced this finding was negative appraisals of unusual psychological experiences (which does not have a direct corollary in the ISMI scale

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used in the present study). The study did not find a relationship between stigma and later social anxiety or suicidality, and did not test for an association with psychotic symptoms other than nonbizarre ideas (perceptual abnormalities, disorganized speech and unusual thought content were not associated with stigma at baseline and were thus not included in longitudinal analyses). In short, our findings were consistent with those of others using somewhat different methodologies. There seems to be an emerging hypothesis in the field that internalized stigma leads to depressive symptoms which then impedes recovery among people with SMI. Further more rigorous studies would be needed to test this hypothesis more fully. The picture is less clear for psychotic symptoms, as studies using differing methodologies have found inconsistent results. We did find a robust relationship between internalized stigma and psychotic symptoms, so we encourage our colleagues to continue to investigate this relationship. Our findings suggest some directions for future research that might elucidate characteristics of potentially helpful interventions. Future research might investigate whether interventions that focus on increasing a feeling of belonging may work against alienation, promoting engagement with other people and with society. Exploratory analyses suggest that future research might focus on inducing in participants a feeling of wholeness and growth (e.g., the opposite of spoiled). Furthermore, and perhaps especially for homeless people, future work might focus on helping them come to terms with or advocate against discrimination experiences. Exploratory analyses also indicate that future research that targets inducing hope among participants that is focused on the hope of having a good life and contributing to society are likely to be associated with reduced symptoms at later time points. Studies guided by the recovery model are likely to focus on such targets. 4.1. Limitations A substantial number of Veterans in the sample were lost to follow-up or provided incomplete data. It is unknown whether those with higher or lower stigma, or higher or lower symptoms would be more difficult to find. The internal consistency reliabilities for the ISMI were lower in the present sample than in the original reference sample (Ritsher [Boyd] et al., 2003). These alpha levels are consistent with those in other studies using the ISMI around the world (reviewed in Boyd et al., 2014) and reflect the “shrinkage” that typically occurs when a scale is given to a new sample (Crano et al., 2015). A substantial number of analyses were run, without formal controls on Type I error, and with po 0.05 as the significance threshold throughout. For this reason, we are presenting our individual item level analyses as exploratory and we recommend that future research investigate the stability of these potential findings across samples and contexts. Assessment was completed by clinical case managers, which could have biased participants’ responses. This study used a specific sample of homeless veterans with SMI; thus, results may have limited generalizability. Site-level differences and participation in the Vet-toVet intervention were statistically controlled in the analyses, but it is possible that other interventions such as medications might have affected the scores over time on variables used in the analyses. Major life changes such as employment, personal health, etc. could also have served as confounders. The case managers were not blind to the research design. Due to the way “homelessness” was defined (see definition above), participants were not all without a place to live at the time of the first interview, or at later time points. Finally, this study used a quasi-experimental design, limiting the ability to assess causality. In summary, we found that internalized stigma is related to depressive and psychotic symptoms over time among homeless veterans with SMI. Our findings replicate and extend the findings

of other studies and have implications for future research into the potential long-term effects of anti-stigma interventions on mental health outcomes. In particular, future work could investigate whether interventions that work against alienation and discrimination experience could have the distal effect of reducing depressive and psychotic symptoms. Our findings also supported the relationship of stereotype endorsement and social withdrawal with increased depressive symptoms, and, to a lesser extent, with increased psychotic symptoms. Exploratory item-level analyses suggest focusing future research on promoting a sense of wholeness and growth, interpersonal engagement, and coping with discrimination, as well as the hope of having a good life and contributing to society. Taken together, these topics support using the recovery model as a guide to future work.

Contributors All authors contributed to the writing and editing of the manuscript and interpreted analyses. In addition, Dr. Boyd conceptualized the study and Dr. Hoff provided expertise about the parent study that produced the dataset.

Conflict of interest The authors have no conflicts of interest to report.

Acknowledgement Data were provided by NEPEC via the VA Office of Patient Care Services Data Transfer Agreement SNCMI (2011-02).

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