The impact of internalized stigma, patient activation, autonomy preference, and illness self-management on intensive service use among individuals with schizophrenia

Background: Fear of stigmatization has been shown to discourage individuals from seeking mental health treatment and adhering to treatment regimens, and it may impact mental health outcomes in other ways. Internalized stigma (self-stigma) is the damage done to an individual\u27s self-esteem and self-concept when one applies public stigma to oneself. Individuals with high levels of self-stigma may endorse stereotypes of the mentally ill, such as being untrustworthy or incompetent. Such beliefs may lead to poor self-management of their condition, which has been linked to negative treatment outcomes, such as frequent intensive service use in the form of hospitalizations and emergency room visits. The impact of internalized stigma on illness self-management and health care outcomes may be mediated by autonomy preference (the degree to which individuals want information about their condition and to make decisions about their own care) and patient activation (the skills, knowledge, and confidence an individual has related to his condition). Autonomy preference and patient activation have been linked to improved self-management behaviors and health care outcomes in general health populations, but less work has been done in psychiatric samples. Methods: A secondary analysis was conducted on data collected from 118 participants in a randomized controlled trial of an Illness Management and Recovery (IMR) Program. Measured variable path analysis and hierarchical regression were used to explore the roles of internalized stigma, autonomy preference, and patient activation on illness self-management and intensive service use (assessed via hospitalization and emergency service use). Results: The proposed model had acceptable fit (Chi-square = 10.76, df = 9, p = .29, RMSEA = 0.041 (90% CI for RMSEA = 0.0, .12). Internalized stigma was found to impact illness self-management; this relationship was partially mediated by patient activation. The model did not predict service use. Regression models indicated that military veterans had a shorter length of hospitalization, and that an individual\u27s level of illness management predicted number of ER visits at 9 months. Conclusions: Interventions targeting an internalized stigma and patient activation may enhance illness self-management. Further exploration of the relationship between the IMR measure and service use is needed