The Role of Internalized Stigma in Modulating Hope, Self-Esteem, and Self-Efficacy among Outpatients with Mental Illness

Background: Mental health disorders influence emotions and behavior and frequently result in stigma, particularly personal stigma, where affected individuals internalize societal biases. This study explores the relationship between internalized stigma and hope, self-esteem, and self-efficacy in individuals with mental illness. Objectives: The aim was to investigate the relationship between internalized stigma and hope, self-esteem, and self-efficacy in patients with mental illness and to contribute to the discourse on mental health care. Methods: A cross-sectional study involving 126 mental illness outpatients from Amirkabir Hospital in Arak, Iran, was conducted. Instruments such as the Internalized Stigma Of Mental Illness (ISMI) Scale, Schneider's Dispositional Hope Scale, Rosenberg's Self-Esteem Scale, and the General Self-Efficacy Scale were utilized. Data were analyzed using statistical methods. Results: In this study of 126 participants (54% women, 46% men; ages ranging from 18 to 89), the average score for internalized stigma was 61.04 ± 18.37. There were significant negative correlations observed between self-stigma and hope (r = -0.658, P < 0.001), self-esteem (r = -0.666, P < 0.001), and self-efficacy (r = -0.641, P < 0.001). No significant relationships were identified with socio-demographic factors such as age, gender, and marital status. However, a significant relationship was observed between education level, self-stigma, and self-efficacy. Conclusions: The study confirms that internalized stigma significantly affects hope, self-esteem, and self-efficacy in patients with mental disorders. The findings emphasize the necessity for improved psychological services and educational programs to strengthen these factors, thus diminishing the impact of stigma and enhancing patients' lives.

The human body and mind exhibit a profound interconnectedness, with each significantly influencing the other.Physical diseases manifest through observable symptoms, whereas mental and nervous disorders affect emotions, feelings, and behaviors, often starting as indistinct sensations.Despite advancements in mental health care and the availability of effective treatments, many individuals still hesitate to seek these services (1).
According to the World Health Organization (WHO), 25% of the global population experiences mental disorders, with 6% enduring severe conditions.Currently, approximately 450 million people are dealing with these challenges, positioning mental disorders as a significant contributor to global ill health and disability.Regrettably, a considerably smaller percentage of affected individuals seek treatment, and even among those who do, adherence to continuous and appropriate treatment is frequently lacking (2).
The World Health Organization (WHO) characterizes stigma as a mark of shame, disgrace, and ostracism, resulting in the stigmatized individual facing discrimination and exclusion from social activities.Stigma is a complex and multifactorial issue that operates on various levels (3).
This study investigates self-stigma in mental disorders, focusing on the significant alterations in selfperception that develop as individuals internalize societal biases and adopt negative views towards 2 Iran J Psychiatry Behav Sci.2024; 18(1): e139613.themselves.Self-stigma generates feelings of devaluation, ostracization, and secrecy, prompting withdrawal.The internalization of negative stereotypes initiated a harmful cycle of self-criticism and diminished self-esteem (4).
Hope, described as the resilient and optimistic expectation of achieving goals, is identified as a critical factor associated with enhanced attachment, improved nutrition, attentive care, and strong social support in facing challenges, as indicated by research findings.Individuals possessing higher levels of hope are more effective in navigating challenges, resulting in superior outcomes compared to those with lower levels of hope (5,6).
Self-esteem, an integral component of one's personality, is crucial in shaping behavioral traits and enhancing personal well-being.Experts recognize its importance for emotional and social adaptation, a notion that recent research has underscored (7).
Self-efficacy is essential in determining how time is allocated to tasks, how one persists in the face of challenges, and adaptability in various situations.It also significantly influences individuals' cognitive patterns and impacts their emotional responses within the societal context (8).
Studies show that individuals facing high levels of stigma, especially those who anticipate discrimination, often experience a range of negative outcomes.These outcomes include increased economic instability, characterized by higher unemployment rates and lower income (9), challenges in adhering to treatment (10), reduced self-esteem (11), and decreased usage of mental health care services, thereby compromising their overall quality of life (12,13).Furthermore, these individuals may adopt avoidance as a coping mechanism, which can exacerbate their problems instead of resolving them (12)(13)(14).

Objectives
This study aims to explore the relationship between internalized stigma and hope, self-esteem, and selfefficacy among mental illness outpatients.The objective is to enhance understanding of these relationships, contributing to the broader discourse on mental health care and management.

Participants and Procedures
In this cross-sectional study, 126 patients diagnosed with mental illnesses were recruited from the outpatient clinics of Amirkabir Hospital in Arak, Iran.Inclusion criteria for participants were as follows: a DSM-V psychiatric diagnosis, 18 years of age or older, outpatient status, having been diagnosed more than six months prior, and a willingness to participate.Individuals with mental retardation, substance abuse, personality disorders, or severe physical illnesses were excluded.
Participants provided written consent to partake in the study.A questionnaire was used to collect demographic information such as age, sex, education level, marital status, housing situation, and employment status.The study protocol received approval from the Research Ethics Committees of Arak University of Medical Sciences.

Self-Stigma
The Internalized Stigma Of Mental Illness (ISMI) Scale utilized in this study measures internalized stigma across 5 domains: alienation feelings, agreement with stereotypes, perceived treatment by others, societal withdrawal rate, and resistance to stigma.It uses a 4point Likert scale across 29 items.The resistance domain demonstrates a weak correlation and consistency with the other domains (15).

Hope
This study employs Schneider's Dispositional Hope Scale, which consists of 12 items rated on an 8-point scale.It includes 2 subscales -agency thinking and pathways, each with 4 questions.Four additional items are not scored, resulting in a score range from 8 to 64 (5).

Self-Esteem
The Rosenberg Self Esteem Scale, used to assess life satisfaction and self-perception, applies a 4-point Likert scale to ten items, with five reverse scored items.Scores range from 10 to 40, where a higher score indicates greater self-esteem (16).

Self-Efficacy
The General Self-Efficacy Scale, employed in this research, assesses 3 behavioral aspects: the readiness to initiate behavior, persistence in completing tasks, and Iran J Psychiatry Behav Sci.2024; 18(1): e139613.3 resilience to obstacles.It comprises 17 items rated on a 5point Likert scale, with scores ranging from 1 to 5. The maximum total score is 85, and the minimum is 17 (17).

Statistical Analysis
Descriptive statistics were used to summarize the characteristics of the data.Categorical variables were reported using frequencies and percentages, while continuous variables were presented as means ± standard deviation.The chi-square test was utilized to compare categorical variables, and the t-test was employed to compare the means of continuous variables.Correlation coefficients and linear regression were used to analyze the relationships between variables.A P-value of less than 0.05 was considered to indicate statistical significance.The data analysis was conducted using IBM SPSS Statistics v. 22.
The mean score on Schneider's Hope Scale was 45.76 ± 11.93, the Rosenberg Self Esteem Scale averaged 28.76 ± 7.19, and the General Self-Efficacy Scale recorded a mean score of 57.11 ± 16.28.The average total score for patients' internalized stigma was 61.04 ± 18.37.Table 1 categorizes the ISMI scores into minimal, low, moderate, and strong categories (18).The Pearson correlation test showed a strong negative correlation between self-stigma and hope (r = -0.658,P < 0.001), indicating that an increase in selfstigma corresponds with a decrease in hope.Similarly, strong negative correlations were found between selfstigma and self-esteem (r = -0.666,P < 0.001) and between self-stigma and self-efficacy (r = -0.641,P < 0.001), suggesting that an increase in self-stigma is linked to reductions in both self-esteem and self-efficacy.
When comparing the scores of internal stigma, selfesteem, hope, and self-efficacy according to individualsocial characteristics, it was observed that the scores for internalized stigma, self-esteem, hope, and self-efficacy did not exhibit any significant relationships with factors such as age, gender, and marital status.However, a significant relationship was identified between education level, self-stigma, and self-efficacy.Specifically, an increase in education level was associated with a decrease in the score of internalized stigma and an increase in self-efficacy scores (Table 2).

Discussion
Stigma poses a significant global health concern, offering a complex and substantial challenge for individuals with psychiatric disorders.This research delved into the complex relationships between stigma and factors such as self-esteem, hope, and self-efficacy, taking into consideration both individual and social characteristics.
Barlati et al. discovered that 22.3% of patients experienced high levels of internalized stigma (19), and a review from 2014 showed that approximately a quarter to half of the subjects encountered severe stigma (20); our findings align with these studies.However, our research found a lower prevalence of stigma compared to the study by Picco et al. in 2016, where 43.6% of participants reported moderate to severe stigma (21), and the study by Ghanean et al. in 2011, which identified that 39% of individuals experienced similar levels of stigma (22).
This discrepancy may be attributed to our study's inclusion of all psychiatric patients, as opposed to the other studies, which primarily focused on individuals with schizophrenia, potentially explaining the differences in findings (see Table 1).This underlines the importance of recognizing the unique characteristics of various psychiatric conditions, suggesting that the levels of stigma may differ across different mental health diagnoses and highlighting the need for tailored interventions and support systems.The average score on the self-esteem questionnaire for patients was 29.03 ± 7.10.Considering the questionnaire's scoring range from 10 to 40, lower scores indicate low self-esteem, while higher scores suggest high self-esteem.In contrast to our findings, Pal et al. in reported an average self-esteem score of 19.28 ± 4.47 for individuals with mental disorders (23).However, the findings of Picco et al. in, showing an average score of 26.3 ± 5.45, are in line with our study, underscoring that low self-esteem is a common indicator of a mental disorder (24).
Self-esteem is intimately connected to one's mental self-perception, influencing all value-related responses.A positive perception enhances self-worth, whereas a negative perception can deteriorate value and selfesteem.Recognizing the importance of self-esteem in mental health is crucial, as it serves both as a potential symptom and a significant factor in overall well-being (25).
The observed negative correlation between internalized stigma and self-esteem aligns with prior research.Low self-esteem has been acknowledged as a frequent outcome of stigma, highlighting the importance of interventions focused on enhancing selfworth among psychiatric patients.The results indicate that directly tackling stigma could help improve selfesteem and, as a result, overall mental health (26).
The average hope score in this study was 5.80 ± 1.46 on a scale of 8, where higher scores indicate greater levels of hope and lower scores reflect lower levels of hope.Accordingly, the study's population's average hope scores are situated within a moderate range.Mashiach-Eizenberg et al.'s study reported an average hope score of 4.35 ± 1.12, which signifies a medium level of hope.This result is in line with our study, affirming the consistency between our research and prior studies in this field (27).
Our findings are consistent with the research by Morgades-Bamba et al., which reported an average selfefficacy score of 60.2 ± 0.56 among patients with mental disorders (28).Self-efficacy, influenced by cognitive mediators such as thoughts and emotions, may be diminished by negative experiences or stressors like mental illness, potentially leading to anxiety.This demonstrates the intricate nature of self-efficacy within the realm of mental health (29).
This study identified a significant negative correlation between internalized stigma and factors such as self-esteem, hope, and self-efficacy in patients.As internalized stigma increases, these factors tend to decrease, aligning with findings from previous research.
For example, the 2016 study by Picco et al., which involved 280 participants, identified a negative relationship between stigma, self-esteem, quality of life, and performance, with the exception of hope.Our study's findings align with theirs, except in terms of the relationship with hope, which could be attributed to differences in religious contexts (21).
Similarly, a 2016 study from Turkey by Karakas on 60 schizophrenia patients and a 2016 study from Japan by Shimotsu and Horikawa on 1011 outpatients demonstrated that increased internalized stigma Iran J Psychiatry Behav Sci.2024; 18(1): e139613.5 resulted in decreased self-esteem, corroborating our results.These outcomes support the significant impact of internalized stigma on various aspects of mental wellbeing (30,31).Furthermore, research conducted in Iran indicated that more than half of the individuals with severe mental illness experience moderate to high levels of internalized stigma, with lower self-esteem and selfefficacy emerging as key predictors.Despite the influence of cultural factors, treatment adherence was not significantly associated with internalized stigma, highlighting the intricate array of elements that affect perceptions of mental health in this setting (26).
The study by Jahn et al., conducted in the United States, explored the relationship between societal stigma, internalized stigma, self-esteem, and selfefficacy in individuals with serious mental illness.This study highlights the harmful effects of societal stigma on individuals with serious mental illness, showing that internalized stigma, reduced self-esteem, and the ambiguous roles of self-efficacy together mediate the relationship between experiences of stigma and various outcomes of recovery.The findings underline the critical need for interventions that address internalized stigma and self-esteem to improve mental health recovery for individuals with serious mental illness (32).
Internal stigma, hope, self-esteem, and self-efficacy do not exhibit a significant relationship with individualsocial factors such as age, gender, and marital status.However, these elements are significantly associated with education level.In subjects with higher education, stigma appears less pronounced, suggesting that higher education acts as a buffer against devaluing judgments.A study by Park et al. corroborates this, revealing that more educated individuals tend to hold less bias toward mental illnesses and possess a more favorable outlook on the effectiveness of treatment.These outcomes are consistent with our study's findings (33).
The correlations identified in this study between internalized stigma, hope, and self-efficacy reinforce the interconnected nature of these psychological constructs.Recognizing that increased internalized stigma correlates with decreased hope and self-efficacy highlights the necessity for comprehensive interventions that address various aspects of individuals' mental health.Improving hope and selfefficacy could act as protective factors against the negative impact of stigma on mental well-being.

Conclusions
The present study explored internalized stigma among patients with mental disorders, uncovering that it adversely affects self-esteem, hope, and self-efficacy, irrespective of age, gender, or marital status while noting an increase in self-efficacy.These findings highlight the importance of enhancing psychological services and educational programs to bolster crucial elements such as hope and self-esteem.Such initiatives can diminish the influence of stigma, fostering empowerment, efficiency, and a general enhancement in patients' lives.

Table 1 .
Mean ISMI Score Classification a a Values are expressed as No. (%) unless otherwise indicated.

Table 2 .
Comparisons to Individual-Social Characteristics a t-test.bANOVA test.