Effectiveness of Self-Stigma Interventions for Persons with Serious Mental Illness: A Systematic Review

Purpose: Self-stigma has been identified as a key mechanism affecting health and mental health outcomes for persons with serious mental illness. The negative effects of self-stigma include both reduced help-seeking behavior and treatment self-efficacy. In the past ten years self-stigma interventions have emerged in order to address these negative effects. The interventions developed have drawn upon a combination of theoretical foundations including cognitive therapy, narrative therapy, and psychoeducation.  Not only have previous systematic reviews noted the need for more clarity on the theoretical foundations but also they have also conceptualized and characterized the theoretical foundations of the different interventions in an inconsistent manner. Also, these reviews have not assessed the level of outcome attainment (significant versus non-significance) while accounting for study rigor.  Therefore, this systematic review addresses the following research questions: 1) what is the methodological rigor of intervention studies that target adults with serious mental illness; and 2) What is the effectiveness of self-stigma interventions on outcomes of self-stigma and self-efficacy accounting for methodological rigor, and 3) what types of intervention theories are most effective?

Methods: A systematic search was conducted in four electronic databases. Only English peer reviewed articles published between 2000-2017 were searched. Inclusion criteria were quantitative evaluations of interventions specifically addressing self-stigma in persons with serious mental illness. The methodological quality of the studies was evaluated using an adapted Methodological Quality Rating Scale (MQRS) by Miller (1995) using a summary score of 15 items. The outcomes assessed were measures of self-stigma and self-efficacy. Outcome attainment (i.e. significance accounting for high or low rigor scores on the MQRS) was determined using a methodology described by Auslander et al. (2012). Comparisons were made based on types of intervention theory. 

Results: The search yielded a total number of 17 studies. The methodological quality of interventions had a mean MQRS rating of 8.28, median score of 9.5, and a range of 2-14.  Interventions classified as other which came from a range of theories had the lowest mean MQRS scores (5.2), followed by cognitive theory (7.5), psychoeducation (8.5), and narrative therapy which rated the highest (13). After outcome attainment scores were calculated, narrative therapy interventions appeared to be slightly more effective in improving self-stigma when accounting for methodological rigor.  However, results did not indicate that one type of intervention was more or less effective in improving self-efficacy

Conclusions and Implications: Narrative therapy had the highest outcome attainment scores on reduction of self-stigma when accounting for quality. However, it should be noted that other systematic reviews have differently grouped interventions by theoretical foundation and have had contradicting results. This indicates the need for greater consistency and further development of theoretically informed self-stigma interventions that are effective.   Moreover, because self-stigma is often cited as an important mechanism affecting mental health service use, this research has potential to deepen our understanding of increasing use of services and improve outcomes in people with serious mental illness.