INTERNALIZED STIGMA AS A PREDICTOR OF EMPLOYMENT STATUS IN PATIENTS WITH SCHIZOPHRENIA

Abstract

Background: Employment is an important social determinant of health, especially for individuals with mental illnesses where it was found that gainful employment is crucial for both functional and clinical recovery. However, individuals with mental illnesses face significantly higher levels of unemployment compared to their counterparts without. Within different diagnoses of mental illnesses, it was found that patients with schizophrenia face higher levels of unemployment compared to patients with other diagnoses. Numerous qualitative studies have identified an association between internalized stigma and unemployment in individuals with schizophrenia, however, fewer quantitative studies have examined the specific relationship between the two factors. Therefore, we aim to elucidate the relationship between employment status and internalized stigma, and more specifically, its domains in patients with schizophrenia. Methods: One hundred and seventy-nine patients with schizophrenia were included in this study. Illness severity was assessed using the Clinical Global Impression scale, internalized stigma was measured using the Internalized Stigma of Mental Illness scale (ISMI), and demographic information including employment status was collected. For the purpose of analysis, employment status was categorised into two groups, with the employed group consisting of those under full-time and part-time employment, as well as full-time students. While the unemployed group consisted of individuals who were unemployed at the time of assessment. The ISMI assesses five domains of internalized stigma, which are alienation, stereotype endorsement, discrimination experience, social withdrawal and stigma resistance. Multiple logistic regression, controlling for demographic and clinical factors, was conducted to identify the domains of internalized stigma associated with predictors of employment status. Results: One hundred and two participants were employed and seventy-seven were unemployed. The employed group was younger, had shorter duration of illness, more years of education and less severe illness level (all p < .001). The unemployed group consisted of more females and divorced individuals (all p < .05). The unemployed group reported significantly higher levels of internalized stigma in the total score, as well as stereotype endorsement, discrimination experience, and social withdrawal domains (all p < .05). Mean total ISMI scores for employed and unemployed groups were 62.15 (SD = 13.69) and 67.52 (SD = 13.94) respectively. Multiple logistic regression analysis, controlling for demographic and clinical factors, found that years of education (OR = 0.835, p < .05), and two domains of the internalised stigma scale, stereotype endorsement (OR = 1.210, p < .05) and stigma resistance (OR = 0.854, p < .05), were associated with employment status. Discussion: More years of education and higher level of stigma resistance were found to be associated with being employed, suggesting that stigma resistance along with education may play protective roles in both obtaining and sustaining employment in patients. Higher level of stereotype endorsement was found to be associated with being unemployed, suggesting that patients who agree with the stereotypes about mental illness may face greater difficulties in gaining and sustaining employment. Hence, tailored interventions focused on specific domains of internalized stigma may be crucial components of any services targeted at improvement of occupational functioning in patients with schizophrenia.