Stigmatization refers to the process of labeling and stereotyping a group of people with undesirable characteristics, resulting in the negative consequence of separation, status loss and discrimination against these people (1). In general, stigma can be further categorized into several distinct but related subtypes, namely perceived public stigma, self-stigma and affiliate stigma. Public stigma denotes the endorsement of related stereotypes and prejudice as well as the manifestation of discrimination from the general public (2). Self-stigma is developed when individual with mental illness internalize the socially-endorsed negative stereotypes of the illness (2), while affiliate stigma refers to the caregivers’ internalized perceived public stigma toward patients (3). In particular, self-stigma has received increasing attention in psychiatric research, especially in people suffering from psychotic disorders. Literature has consistently indicated that a large proportion of patients with schizophrenia have experienced stigmatization and discrimination against their mental health condition during their lifetime (4). A recent meta-analysis reported that around one-third of schizophrenia patients exhibited high levels of self-stigma, with such undesirable situation being particularly common in southeastern Asian countries (5). Prior research suggested that greater self-stigma would impede treatment adherence and recovery process among patients with psychotic disorders (6–8). Accumulating data have further revealed that increased self-stigma may be associated with poor illness outcomes including greater symptom severity, elevated risk of psychiatric comorbidity, suicidal ideation and psychiatric hospitalization, reduced employment opportunity and lower functional status in patients with psychotic disorders (5).

Of note, the majority of prior studies examining self-stigma in psychotic disorders focused on patients with chronic illness (5, 9–11). Relatively few studies have systematically investigated stigmatization in the early course of psychotic disorder (12–19), and some of these studies in fact examined other forms of stigma rather than self-stigma in early psychosis patients, such as the disclosure form of stigma (16, 19) and perceived public stigma (15, 17, 18). We have previously observed significant association between perceived public stigma and self-stigma in patients with first-episode psychosis (FEP) (12). Our more recent study found that female sex, longer duration of untreated psychosis (DUP) and more severe positive symptoms at baseline were associated with greater self-stigma in early psychosis patients at 3-year follow-up (13). Some recent studies, albeit on chronic schizophrenia, have also suggested that patients with antipsychotic-induced motor side-effects may be more likely to experience increased self-stigma (20, 21). However, most earlier research, including our past studies, primarily focused on patients at younger age (12–16) (as early intervention services mainly treated young FEP patients). Given that there may be significant variations in illness presentations, treatment outcomes and service need between patients with typical age of onset (i.e., late adolescence or early adulthood) and those having their psychosis manifested at later years (22, 23), together with recent extension of some early intervention services to cover a wider adult age range (e.g., in United Kingdom and Hong Kong) (23, 24), more research is required to clarify self-stigma and its associated factors in early psychosis patients at higher-age groups.

To this end, the current study aimed to examine the prevalence and correlates of self-stigma in a cohort of Chinese adult patients with early psychosis. To ensure comprehensive evaluation of factors associated with self-stigma, a wide array of variables encompassing socio-demographics, premorbid adjustment, onset profile, symptomatology, treatment characteristics and side-effects were included in our analysis.

The current study aimed to investigate the rate and correlates of self-stigma in a Chinese cohort of adult patients with early psychosis. Our results showed that approximately 28% of early psychosis patients exhibited moderate-to-high levels of self-stigma. Among various factors, female sex, younger age, longer DUP and better insight were found to be independently associated with greater self-stigma.

Our result on the prevalence of self-stigma in early psychosis patients largely accords with those observed in the literature on schizophrenia and other psychoses (ranged: 16.5 to 51%, with most studies reporting prevalence of self-stigma above 30%), with a recent meta-analysis estimated that 35.8% of schizophrenia patients displayed high self-stigma (5). Of note, it may be difficult to directly compare our data with previous findings due to significant cross-study methodological variation including the use of different assessment instruments for self-stigma and the heterogeneous characteristics of the patient samples (e.g., being evaluated in different stages of the illness) as earlier research primarily examined patients with chronic schizophrenia. Cross-cultural differences may also contribute to discrepant findings on self-stigma. Recent meta-analyses showed higher frequency of high self-stigma and greater stereotype endorsement in schizophrenia patients from Asian countries compared to the others (5, 40). Literature suggested that perceived stigma and self-stigma in people with mental illness may be greater in regions with relatively group-oriented cultures (e.g., Asian and Chinese populations) than those regions with more individual-oriented cultures (e.g., countries in Europe and North America) (41). However, as Hong Kong is a metropolitan city with comparatively more westernized culture, the effect of Chinese cultural factors on stigmatization in mental illness would likely be less pronounced than those regions associated with more traditional, collectivistic Chinese culture. Nevertheless, our results reveal that a significant proportion of patients experienced self-stigma in the early phase of psychotic disorder.

Many previous studies observed lack of sex difference in self-stigma among patients with severe mental illness including schizophrenia (5, 40). Our finding that female patients had greater self-stigma than the male counterparts is, however, in line with some earlier studies on chronic schizophrenia (42, 43), as well as young early psychosis sample in Hong Kong (13). Mixed findings were also noted in the association between age and self-stigma in patients with psychotic disorders. Many past reports revealed no significant association between age and self-stigma (5, 40). Nonetheless, our finding that younger patients had greater self-stigma than older patients concurs with some prior studies which demonstrated that self-stigma level increased with decreasing age of schizophrenia patients (44–46). It is plausible that patients are less exposed to stigmatization and its associated distress with increasing age because they might be more accustomed to these negative societal attitudes (45). Other investigators postulated that older patients may be able to cope with psychiatric symptoms more efficiently than younger patients (47), and such enhanced coping may help buffer the adverse effect of stigmatization (45, 48).

We found that patients with longer DUP had greater self-stigma. This is consistent with our previous study in young patients with early psychosis and a number of past reports on FEP samples (16, 17). In fact, prior research has suggested that perceived public stigma and self-stigmatization may increase the likelihood of delayed help-seeking and decreased use of psychiatric service (49), including first-episode patients (50). Alternatively, patients with prolonged DUP may experience a longer duration of exposure to perceived stigma, which in turn leads to increased susceptibility to internalization of stigma, relative to those with shorter DUP (13, 51). Hence, reduction of treatment delay by early detection of and timely intervention to initial psychosis would be critical for lowering the risk of self-stigmatization in early psychosis patients. In agreement with many previous studies examining correlates of self-stigma in psychotic disorders (5), our results demonstrated that higher level of insight was associated with greater self-stigma. Notably, a growing body of research has investigated the inter-relationship between self-stigma, insight and depression in patients with psychotic disorders, and has revealed that self-stigma mediates the association between insight and depression (52). Accumulating data further suggested that self-stigma may moderate the relationships between insight and other psychosocial variables. For instance, associations of good insight with increased demoralization, lower self-esteem, poorer life satisfaction and higher levels of hopelessness were stronger as self-stigma levels increased in schizophrenia patients (38, 53, 54). Given that insight to illness is an important therapeutic target in early intervention for psychosis, careful evaluation of the potential negative impact of improved insight on stigma internalization should be regularly conducted to minimize the risk of exacerbation of self-stigma levels among those patients with better insight. Conversely, contrary to some (4), though not all, past studies (12, 55–59), we did not find any significant association of self-stigma with positive, negative or depressive symptoms. One possible explanation is that our patient cohort were clinically stabilized with antipsychotic treatment, with relatively low symptom severity. The limited variance in symptom ratings may therefore obscure the potentially significant association between self-stigma and these symptom domains.

The current study has several important merits. First, this is among the few studies to examine self-stigma in the early course of psychotic disorders, with specific focus on adult patients with wider age range. Second, a comprehensive array of variables, including premorbid adjustment, onset profile, various symptom domains and treatment characteristics, were incorporated for analysis of correlates for self-stigma. However, several methodological limitations should be considered in interpreting the study results. First, the cross-sectional design precludes us from establishing causality between self-stigma and its associated correlates. Moreover, as this study recruited and assessed patients shortly after the end of the EASY programme, we were not able to evaluate the trajectory of patients’ self-stigma levels over time since service entry and the potential effect of early intervention on reducing self-stigma. Second, other variables that may be related to self-stigma, including cognitive functioning, meta-cognitive capacity, social perception, theory-of-mind abilities, illness appraisal and coping strategies, were not examined in this study. Third, SSS-S is a brief, albeit well-validated, scale for assessing self-stigma in patients with schizophrenia and related psychoses. Adoption of more comprehensive assessment scales such as internalized stigma of mental illness scale (ISMI) (60) and perceived devaluation and discrimination (PDD) (61) would provide a more refined evaluation of self-stigma and its related constructs in early psychosis. Fourth, this study only included adult patients aged 26–55 years, while the majority of early psychosis studies focused mainly on adolescent and young adult patients. This may therefore compromise the comparability of our study findings with the literature of early psychosis research.

In conclusion, our results show that more than one-fourth of Chinese adult early psychosis patients exhibited moderate-to-high levels of self-stigma. Female sex, younger age, longer DUP and better insight were independently associated with greater self-stigma. Owing to the fact that self-stigma is prevalent in the initial course of illness and may impede the recovery process, comprehensive assessment of self-stigma and regular monitoring of its adverse impact on clinical outcome and psychosocial functioning should be performed on a regular basis to facilitate early detection of and prompt interventions to patients at risk of developing high self-stigma. In fact, recent meta-analytic reviews have indicted efficacy of various psychological interventions in lowering self-stigma in patients with psychotic disorders (62, 63), and group therapies (such as assertive training and psychoeducation programs) may be particularly useful for patients with significant though relatively less severe self-stigma (62). A conceptual framework has also recently been proposed to adequately address stigma for early psychosis patients by delineating how distinct forms of stigma (including self-stigma and perceived public stigma) are linked to different treatment stages of early intervention service (64). This underscores an important unmet need to minimize self-stigma in early psychosis. Further research is warranted to unravel the longitudinal relationship between self-stigma and various illness and clinical variables so as to identify crucial treatment targets to alleviate self-stigma in the early phase of psychotic disorders.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (HKU/HA HKW IRB). The patients/participants provided their written informed consent to participate in this study.

WC designed and conceptualized the study. RC, CN, and SKWC conducted statistical analysis and wrote the first draft of the manuscript. WC, RC, and CN interpreted the study data. WC and RC revised and finalized the manuscript. All authors provided critical feedback to the manuscript and approved the final manuscript.