In-Patient With Schizophrenia, What Effect Does Stigma Compared With Family Perception Of Stigma Have on Seeking Treatment During The Acute Phases?

In-Patient With Schizophrenia, What Effect Does Stigma Compared With Family Perception Of Stigma Have on Seeking Treatment During The Acute Phases?

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In-Patient With Schizophrenia, What Effect Does Stigma Compared With Family Perception Of Stigma Have on Seeking Treatment During The Acute Phases?

INTRODUCTION.

Schizophrenia can be thought of as a condition whereby people interpret reality abnormally. It’s a long-term mental disorder that causes a breakdown in the relationship between thoughts, emotions, and behaviors. Schizophrenia can make it very difficult to control or predict one’s behavior. Schizophrenia is often associated with a lot of stigmas, especially in the acute phases. However, family perception of stigma associated with the same can affect the treatment of this severe mental disorder. This paper offers a systematic review of in-patients with Schizophrenia and how the family perception of stigma associated with it affects the process of seeking treatment.

OBJECTIVES AND SPECIFIC AIMS OF THE RESEARCH.

As outlined above, the main objective of the paper is to conduct a systematic review of the impacts of family perception of the stigma that is often associated with Schizophrenia on the process of seeking treatment, especially during the acute stages of infection. To successfully determine this, it’s imperative to decide on the stigmatization that is often associated with Schizophrenia. This is done by first understanding the meaning of stigmatization and highlighting its types. Stigmatization is the stereotype sets of adverse negative attitudes, incorrect beliefs, and fears about a given health condition. It can be categorized as; public stigma, self-stigma, and label avoidance.  Also, it’s essential to identify the signs and symptoms that are common during the acute stages of Schizophrenia. Furthermore, it’s very vital to determine how different families perceive stigmatization and how this directly affects the patient in question. Lastly, the research aims at finding viable solutions to the stigmatization of schizophrenia patients.

BACKGROUND.

Schizophrenia is a Greek word that was coined in 1911 from two Greek words, schizo(split) and phrene(mind). This was intended to describe the unpredictable thinking of those who had a mental disorder. Symptoms of schizophrenia range from hallucination (auditory, visual, olfactory gustatory and tactile), delusions, disorganized speech, movement disorder, poor concentration, and confusion. Stigmatization associated with this mental disorder is often faced by the patient, family members, relatives, and some close friends.

The research is focused on in patients who have Schizophrenia in the European nations, and the target population is individuals between the ages of 13 to 35. The target population comprises of both the two genders. However, the leading target group is the school going teenagers; this is because Schizophrenia is generally experienced during the early childhood and late stages of adolescence. However, acute stages are often experienced between the ages of 16 to 30. Determining the impacts of stigmatization as far as Schizophrenia is concerned, is very vital in ensuring patients receive appropriate treatment. However, different families perceive the various forms of stigmatization, which dictates how the patient access treatment, especially in the acute stages of infection.

RESEARCH METHODS

Eligibility criteria

To conduct this research, several articles that directly touch on Schizophrenia were selected and reviewed accordingly. However, the articles were further subjected to various eligibility criteria according to the overall objective of the research work.

The below criteria for eligibility (inclusion and exclusion) were applied;

Types of studies

Articles that were accepted for the research work were expected to contain either primary study or secondary studies (other hierarchical studies). The initial study involved research work that included the collection and analysis of the original data. Original data may be collected through; observation, issuance of questionnaires, face to face interviews, and online data analysis. On the other hand, secondary studies rely on analyzing research work from other studies that were conducted in the past. Apart from the type of study used by the scholarly articles, our inclusion criteria also focused on the year the article was published, and the publication status is the article copyrighted. By utilizing these inclusion criteria, 20 scholarly articles met the inclusion criteria. However, they were subjected to other qualification criteria, as outlined below.

Types of participants

For an article to meet this search criterion, it needed to focus on participants aged between 13 and 35 years. Also, the participants interviewed or investigated ought to be patients who had Schizophrenia or were closely related to the patients in question. The patients studied ought to have been in patients who were at the acute stages of infection. Lastly, the participants were required to be citizens in counties located in Europe. Consequently, only ten articles met these inclusion criteria. Fifteen articles met all the requirements except for the fact that 5 of them did not target schizophrenia patients who were at the acute stages of infection.

Types of outcome measures

In these inclusion criteria, articles that involved a thorough analysis of the findings were considered whether they relied on primary or secondary studies. It is required that the articles use reliable quantitative measures in determining the results and outcome of the subject of investigations. An article that vaguely arrived at results without thorough data analysis were left out since they are considered as unreliable. Consequently, two scholarly articles were excluded since they failed to meet this eligibility criteria.

Search Strategy and Source of Information.

Various search strategies were employed in identifying the articles that were considered eligible for the research work. Search strategies that were used include but not limited to; initial search, hand search, search for reference lists in other scholarly articles. Grey literature was excluded from the search since they were not considered to be accurate and precise. The leading search criteria that were used is the initial search. All the studies identified through the initial search were thoroughly assessed for relevance to the review based on a number of aspects. The aspects include but not limited to; the information that was provided in each section of the articles. The sections that were examined include; abstract, title, introduction, and conclusion sections. The databases that were searched are listed below in a timely manner.

Period between 3/3/2020-10/4/2020

keywords: Schizophrenia, acute stages of Schizophrenia, Stigmatization effects related to Schizophrenia.

• Medline
• ClinicalTrials
• CINAHL
• NHSEED
• MIDIRIS
• Science Citation Index
• LearningExpress Library
• Dynamic Health
• EBSCO discovery
• NursingReference citation
• NursingReference citation plus

The following reference list was generated;

1. Bademli, K., & Duman, Z. Ç. (2016). Emotions, Ideas, and Experiences of Caregivers of Patients With Schizophrenia About “Family to Family Support Program.” Archives of Psychiatric Nursing, 30(3), 329–333. doi: 10.1016/j.apnu.2015.12.002
2. Bifftu, B. B., Dachew, B. A., & Tiruneh, B. T. (2014). Stigma resistance among people with Schizophrenia at Amanuel Mental Specialized Hospital Addis Ababa, Ethiopia: a cross-sectional institution based study. BMC Psychiatry, 14(1). doi: 10.1186/s12888-014-0259-y
3. Bifftu, B. B., & Dachew, B. A. (2014). Perceived Stigma and Associated Factors among People with Schizophrenia at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia: A Cross-Sectional Institution Based Study. Psychiatry Journal, 2014, 1–7. doi: 10.1155/2014/694565
4. Brohan, E., Elgie, R., Sartorius, N., & Thornicroft, G. (2010). Self-stigma, empowerment, and perceived discrimination among people with Schizophrenia in 14 European countries: The GAMIAN-Europe study. Schizophrenia Research, 122(1-3), 232–238. doi: 10.1016/j.schres.2010.02.1065
5. Fleischhacker, W. W. (2003). Pharmacological Treatment of Schizophrenia: A Review. Schizophrenia, 75–152. doi: 10.1002/0470861649.ch2
6. Girma, E., Tesfaye, M., Froeschl, G., Möller-Leimkühler, A. M., Müller, N., & Dehning, S. (2013). Public Stigma against People with Mental Illness in the Gilgel Gibe Field Research Center (GGFRC) in Southwest Ethiopia. PLoS ONE, 8(12). doi: 10.1371/journal.pone.0082116
7. Girma, E., Möller-Leimkühler, A. M., Müller, N., Dehning, S., Froeschl, G., & Tesfaye, M. (2014). Public stigma against family members of people with mental illness: findings from the Gilgel Gibe Field Research Center (GGFRC), Southwest Ethiopia. BMC International Health and Human Rights, 14(1). doi: 10.1186/1472-698x-14-2
8. Goldstein, M. J. (1980). Family Therapy during the Aftercare Treatment of Acute Schizophrenia. The Psychotherapy of Schizophrenia, 77–89. doi: 10.1007/978-1-4684-3770-6_7
9. Grover, S., Aakansha, S., & Mattoo, S. (2016). Stigma associated with mental illness: Conceptual issues and focus on stigma perceived by the patients with Schizophrenia and their caregivers. Indian Journal of Social Psychiatry, 32(2), 134. doi: 10.4103/0971-9962.181095
10. Kadri, N., Manoudi, F., Berrada, S., & Moussaoui, D. (2004). Stigma Impact on Moroccan Families of Patients with Schizophrenia. The Canadian Journal of Psychiatry, 49(9), 625–629. doi: 10.1177/070674370404900909
11. Kane, J. C., Elafros, M. A., Murray, S. M., Mitchell, E. M. H., Augustinavicius, J. L., Causevic, S., & Baral, S. D. (2019). A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries. BMC Medicine, 17(1). doi: 10.1186/s12916-019-1250-8
12. Kerr, A. N. (2007). Individual Differences Effects on Schizophrenia Stigmatization. PsycEXTRA Dataset. doi: 10.1037/e652972007-001
13. Kooyman, I., & Walsh, E. (2011). Societal Outcomes in Schizophrenia. Schizophrenia. 644–665. doi: 10.1002/9781444327298.ch31
14. Lindesay, J. (n.d.). De-stigmatization of elderly people with early- or late-onset Schizophrenia. Psychosis in the Elderly, 123–134. doi: 10.4324/9780203336984_chapter_10
15. Margetić, B., Aukst-Margetić, B., Ivanec, D., & Filipčić, I. (2008). Perception of Stigmatization in Forensic Patients With Schizophrenia. International Journal of Social Psychiatry, 54(6), 502–513. doi: 10.1177/0020764008090842
16. Paunović, G., Nenadović, M., Janković, Z., & Vojvodić, P. (2013). 2290 – Sociodemographic characteristics of hospitalized patients with Schizophrenia. European Psychiatry, 28, 1. doi: 10.1016/s0924-9338(13)77149-9
17. Reddy, D. P. V. (2012). Stigma Among Caregivers/Family Members With Persons of Mental Illness. Paripex – Indian Journal Of Research, 3(1), 165–168. doi: 10.15373/22501991/jan2014/52
18. Shafti, S. S. (2015). Odyssey of ‘Negative Symptoms’ of Schizophrenia: Rehabilitation vs. Stigmatization. Current Psychopharmacology, 4(1), 40–51. doi: 10.2174/2211556004666150918193742
19. Shrivastava, A., Bureau, Y., & Johnston, M. (2012). Stigma of Mental Illness-1: Clinical reflections. Mens Sana Monographs, 10(1), 70. doi: 10.4103/0973-1229.90181
20. Sousa, S. D., Marques, A., Rosário, C., & Queirós, C. (2012). Stigmatizing attitudes in relatives of people with Schizophrenia: a study using the Attribution Questionnaire AQ-27. Trends in Psychiatry and Psychotherapy, 34(4), 186–197. doi: 10.1590/s2237-60892012000400004
21. Urban-Kowalczyk, M., & Kotlicka-Antczak, M. (2019). PLASMA β – ENDORPHIN CONCENTRATION AND SCHIZOPHRENIA ACUTE TREATMENT OUTCOME. doi: 10.26226/morressier.5d1a037a57558b317a1409d4
22. Wan, K.-F., & Wong, M. M. (2019). Stress and burden faced by family caregivers of people with Schizophrenia and early psychosis in Hong Kong. Internal Medicine Journal, 49, 9–15. doi: 10.1111/imj.14166
23. Zelst, C. V. (2009). Stigmatization as an Environmental Risk in Schizophrenia: A User Perspective. Schizophrenia Bulletin, 35(2), 293–296. doi: 10.1093/schbul/sbn184

Explicit study selection criteria were applied accordingly to ensure that the study materials selected are very relevant to the research topic. Consequently, the 23 articles that were initially identified were cut down to 15. The 15 articles passed the inclusion, as mentioned earlier criteria. Also, they are peer-reviewed articles hence have been approved by various experts and publishers for use in any research work.

METHODS OF THE REVIEW (DATA COLLECTION PROCESS).

Various processes were used in collecting data that is very relevant to the research topic. The processes involved are highlighted below.

Assessment of methodological quality.

Various relevant databases were searched for systematic reviews. Different organizations have developed tools that are used for reviewing articles that are often published in scholarly databases. In order to come up with a reliable method of reviewing the articles, various review databases were examined. The databases searched include but not limited to; PubMed, Cochrane Handbook for Systematic Reviews of Interventions, Joanna Briggs Institute(JBI) Reviewers Manual, Critical Appraisal Skills Programme(CASP), Centre for Reviews and Disseminations, Scottish Intercollegiate Guidelines Network(SIGN) and the National Institute For Clinical Excellence. A total of 10 tools for methodological quality assessment were used. JBI had the highest number of tools followed closely by CASP.

These tools are used in assessing the methodological quality of articles by evaluating the risk of bias, cohort, and case-control studies. However, methodological assessment of quality, in this case, was dependent on analyzing the risk of bias. The best tool for assessing the risk of bias is Cochrane’s collaboration tool. Consequently, Cochrane’s collaboration tool, COSMIN checklist, and The Methodological Index for Non-randomized Studies (MINORS) were the main tools that were employed for methodological quality assessment of the studies that were eventually included for the research.

Four primary sources of systematic bias were analyzed to ensure that the selected studies were free from bias. The sources of systematic bias that were identified include but not limited to; performance bias, selection bias, detection bias, and attrition bias. The sources are discussed in detail as follows;

• Selection bias

Selection bias results typically from the way comparison groups are assembled. The studies were examined using tools such as MINORS. MINORS is often used in checking non-randomized studies. It helped in identify studies that involved studies that were non-randomized and eliminating them accordingly since they are considered of poor quality in terms of methodological analysis. Cochrane’s collaboration tools also came in handy in eliminating studies that were marred with selection bias. The two tools were used in removing a total of two articles which exhibited selection bias.

• Performance bias

Experienced as a result of systematic differences in the care given to individuals or groups of participants. Any article that exhibits a performance basis should not be used for any research or secondary study. This is because their method of data collection is questionable. Cochrane’s tool is very effective in identifying articles that exhibit this type of bias. Thanks to Cochrane’s collaboration tool, we eliminated one study that was biased in giving care to its participants (schizophrenia patients)

• Detection bias

Systematic differences between the comparison groups in outcome assessment. Detection bias can be detected through analysis using Cochrane’s collaboration tool. This tool to help in eliminating any study that exhibited detection bias. Fortunately, all the 23 study articles were free from detection bias.

• Attrition bias

Systematic differences between the comparison groups in the loss of participants in the study. After using the various tools in measuring this form of bias, three articles exhibited attrition bias. However, they were still included in the research work since they are very relevant to the research topic.

Lastly, the COSMIN checklist was developed upon discussion among experts and testing of the scoring system on the 23 articles. Four response options were defined for each item that was included in the COSMIN list. The response options are; excellent, good, fair, and poor. Quality measurement is later on obtained by taking the lowest rating of any given item in the COSMIN box. Consequently, 10% of the studies were rated as excellent, 25% were good, 30% were of fair quality while the remaining (35%) were of poor quality

Data Extraction

A number of data extraction tools will be used during the research work. The primary data extraction tool that will be used is the software provided by Cochrane’s collaboration software. Other data extraction tools that will be employed include but not limited to; excel spreadsheet, pen, and paper. A standardized form, inclusion and exclusion criteria will be used to aid in the data collection process. PICOT (Population, Intervention, Comparison, Outcome, and Type) framework will be employed in selecting the elements of the standardized form. Below is an example of a form that might prove vital during the data extraction process.

Data Synthesis

The choice of synthesis method should always be justified in the protocol based on the scoping characteristics of the studies that have been included for secondary analysis concerning variability between studies in sample size and study design. Two methods of data synthesis will be employed. Namely, narrative data synthesis and quantitative data synthesis. The two forms of data synthesis that will be applied are discussed as follows;

• Narrative synthesis.

Narrative synthesis often involves tabulation and visualization of the respective primary studies that have passes selection criteria with supported text and arguments that explain the context of the studies. A narrative synthesis will be used in organizing primary studies that were marred with bias. To conduct effective narrative synthesis, tables will be constructed from the extraction forms that will be developed during the data extraction phase. A narrative synthesis will prove vital during the synthesis phase since it provides a detailed statement of the measured effect reported in each study. It will help in determining cases whereby the validity of the primary studies varies by huge margins hence making it easier to give more weight to some primary studies to ensure the research work is very accurate. During Narrative synthesis, the PICOT framework from the extraction table will be used to determine essential studies as far as the research topic.

• Quantitative data Synthesis

Quantitative data synthesis will be applied in measuring the effect of the interventions of the primary studies. This is because it provides a combined effect and measure of the variance of intervention between the different studies. Quantitative synthesis enables an in-depth study of the impacts of effect modifiers, making it more convenient in predicting the outcomes of the interventions under varying environmental conditions. To perform quantitative analysis, meta-analysis and Meta-regression will be used to identify studies whose interventions can remain relevant even in changing environmental conditions.

To combine the data from different primary studies, the quantitative synthesis will be used after selecting the studies that have much weight using the narrative combination. To achieve this, pooling of individual effects will be employed with fixed or random effects of statistical models. Fixed effect models will be used in estimating the combined effects with the assumption that there is a single actual underlying effect among all the other primary studies that have been selected for the overall research work. On the other hand, random effect assumes that there is an uneven distribution of impact depending on the characteristics of the study, thanks to PICOT analysis. Consequently, primary studies with much weight will be given priority during data synthesis. In addition, data that is consistent among all the other studies will be used in the final research work since they are considered to be accurate and very relevant to the research topic.

REVIEW OF RESULTS

Description of selected studies.

A total of 23 papers were identified using a suitable search strategy. The studies were selected from a number of reputable sources hence were deemed fit for the research. However, the studies were subjected to accurate and detailed search criteria. This was done to ensure that the studies were very relevant to the overall research topic. Consequently, out of the 23 studies that were initially identified, 8 of them were eliminated in the various stages of the systematic review. A total of 15 studies passed the inclusion criteria and were approved for the final research. However, out of the 15 sources, three sources exhibited selection and performance bias but were still included for the overall research work. This is because the articles employed detailed primary studies that directly reflected and touched on the research topic. In addition, the articles are peer-reviewed hence are reliable for the research.

Exclusion/inclusion criteria

Exclusion/inclusion

Methodological quality.            

After subjecting all the identified 23 studies to various tools of quality assessment, it turned out that the pieces of literature were of relatively good quality. COSMIN analysis revealed that 35% of the literature were of inferior quality hence were eliminated from the research, 30% were of fair quality. In addition, 10% of the articles exhibited excellent attributes; therefore, they were given much weight and priority. Lastly, 25% of the literature showed good quality.

A funnel plot of the standard difference in mean versus standard error indicates that most of the articles passed the publication bias (p=0.61). In addition, all the articles passed detection and attrition bias, with only three articles out of the 15 (those that were deemed to be fit for the study) exhibiting aspects of performance and selection bias.

Results of individual studies

The studies included a total of 169 participants. The participants were randomly identified and allocated to their respective groups before the actual baseline data collection. However, most of the authors of the primary studies only recorded baseline and follow up data for participants who completed the required intervention programs. A total of 101 participants managed to complete the intervention programs. Follow up emails were sent to authors of the respective studies to inquire about data that were not made available in their publications. However, only a third of the authors who were contacted were able to reply to their respective emails. Furthermore, only data from the two authors will be incorporated into the final research work.

DISCUSSIONS.

            The pooled results from the primary studies demonstrated consistency in the impact of stigmatization in the process of diagnosis and treatment of Schizophrenia. On average, 23% of families in all the studies felt ashamed in seeking treatment for their family members who were at the acute stages of Schizophrenia. Stigmatization was majorly caused by stereotypical bias within the society. The patients, relatives, and even very close friends suffered stigmatization as far as seeking treatment for Schizophrenia, especially in the acute stages of this infection.

One study, in particular, sampled 100 family members who were close to patients or victims of Schizophrenia; it employed the use of hetero questionnaires to collect the sociodemographic data of the family members in question. It also gathers information on family members’ knowledge about the illness. Other data that were gathered include but not limited to; the attitude of the family members toward the patients and their overall perception of stigmatization. In the long run, it was deduced that a good number of families suffer from stigmatization. However, 10% of the family members who completed baseline and follow up studies confided that they perceived stigmatization positively as were not ashamed in seeking medication for the patients even during the acute stages of infection.

However, only three articles directly touched on in-patients who were at the acute stages of schizophrenia infection. Consequently, a meta-analysis could not be completed on all of the fifteen studies that met inclusion criteria. Urban-Kowalczyk & Kotilicka-Antczak measured acute stages of Schizophrenia by determining the level of concentration of b-endorphin hormones.

Limitations.

Some limitations negatively affect the quality of this systematic review.  There were minimal resources that were relevant to the research topic. This made the process of strategic search in the various database very hectic. In addition, few databases contained information and works of literature that were relevant and accurate for a systematic review. In the long run, only 23 articles seemed appropriate as far as a systematic review of the research topic. However, out of the 23 articles that were selected for studies, only 15 met the inclusion criteria. In addition, 5 of the 15 articles which met inclusion criteria could not be effectively used for meta-analysis. Besides, a limited number of studies greatly affected the total number of participants. This had a significant toll on the accuracy of the results in achieving the objectives and aims of the systematic review. The pooled results included a total of 126 participants; this sample size is very small, especially when a common brain disorder such as Schizophrenia is being investigated.

Some of the materials exhibited a high degree of selection and performance bias. The studies include but not limited to Wan et al. and Kadri et al. Kadri et al. focused on a small group of participants hence exhibiting selection bias.

Some of the studies also proved to have employed poor methodology quality. A funnel plot from extraction forms betrayed the fact that one additional study was of deficient quality, thanks to the results of standard mean versus standard error that was deduced from the funnel plot.

In addition, some studies only relied on baseline sampling and surveys without paying keen interest on follow up surveys. Consequently, post-intervention survey results were not included in the studies.

Lastly, the process of reaching the authors of the primary studies seemed fruitless. Authors of studies that only recorded baseline survey data for the participants who completed the intervention program were contacted via email to provide substantial results of the information and data that was not included in their publication. However, only a third of them replied to the email hence making it very difficult to use their studies for the systematic review of the research topic.

Conclusions

The pooled results from all of the fifteen studies show that stigmatization of patients who have Schizophrenia may greatly influence how the patient or their family members seek treatment of the infection, especially when it’s in acute stages. The patients are typically subjected to stereotypical stigmatization; hence most of them feel less confident in society. They feel ashamed of declaring their health conditions. In some cases, the patients may not even be aware of this medical condition. Also, it can be concluded that the way family members of the patient perceive stigmatization of the disease can significantly affect the process of seeking treatment for the disease in the acute stages. This is because the critical phases of the infection may have severe symptoms such as hallucination, memory loss, and lack of concentration. In some cases, the patient may even be considered to be “mad.”

Implications for practice

Stigmatization of Schizophrenia can cause unintended consequences; this is because it may hinder the process of seeking treatment for the same. Patients suffering from this infection should be made aware of the same in cases or scenarios that they may be oblivious that they have this brain disorder. In addition, they should be helped to cope up with stigmatization that is often associated with the infection primarily due to stereotypical categorization in the society. Furthermore, the person who is closely related to the patient such as, family members, relatives, and friends, should be counseled and advised accordingly on how to handle patients who might exhibit signs and symptoms of Schizophrenia. They should be enlightened on how to deal with stigmatization to ensure they can freely seek medication and treatment for their loved ones in case they have Schizophrenia. Lastly, further studies and investigations involving high-quality methodological approaches ought to be employed to ensure there are quality study materials on Schizophrenia.

Implications for Research

This research will go a long way in raising awareness of the stigmatization that is often associated with schizophrenia patients. This will spark more quantitative analysis in the future; hence a long-lasting solution may be realized as far as mitigating the stigmatization among patients and family members of the patients in question.

References

Bademli, K., & Duman, Z. Ç. (2016). Emotions, Ideas, and Experiences of Caregivers of Patients With Schizophrenia About “Family to Family Support Program.” Archives of Psychiatric Nursing, 30(3), 329–333. doi: 10.1016/j.apnu.2015.12.002

Biff, B. B., Dachew, B. A., & Tiruneh, B. T. (2014). Stigma resistance among people with Schizophrenia at Amanuel Mental Specialized Hospital Addis Ababa, Ethiopia: a cross-sectional institution based study. BMC Psychiatry, 14(1). doi: 10.1186/s12888-014-0259-y

Bifftu, B. B., & Dachew, B. A. (2014). Perceived Stigma and Associated Factors among People with Schizophrenia at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia: A Cross-Sectional Institution Based Study. Psychiatry Journal, 2014, 1–7. doi: 10.1155/2014/694565

Brohan, E., Elgie, R., Sartorius, N., & Thornicroft, G. (2010). Self-stigma, empowerment, and perceived discrimination among people with Schizophrenia in 14 European countries: The GAMIAN-Europe study. Schizophrenia Research, 122(1-3), 232–238. doi: 10.1016/j.schres.2010.02.1065

Fleischhacker, W. W. (2003). Pharmacological Treatment of Schizophrenia: A Review. Schizophrenia, 75–152. doi: 10.1002/0470861649.ch2

Girma, E., Tesfaye, M., Froeschl, G., Möller-Leimkühler, A. M., Müller, N., & Dehning, S. (2013). Public Stigma against People with Mental Illness in the Gilgel Gibe Field Research Center (GGFRC) in Southwest Ethiopia. PLoS ONE, 8(12). doi: 10.1371/journal.pone.0082116

Girma, E., Möller-Leimkühler, A. M., Müller, N., Dehning, S., Froeschl, G., & Tesfaye, M. (2014). Public stigma against family members of people with mental illness: findings from the Gilgel Gibe Field Research Center (GGFRC), Southwest Ethiopia. BMC International Health and Human Rights, 14(1). doi: 10.1186/1472-698x-14-2

Goldstein, M. J. (1980). Family Therapy during the Aftercare Treatment of Acute Schizophrenia. The Psychotherapy of Schizophrenia, 77–89. doi: 10.1007/978-1-4684-3770-6_7

Grover, S., Aakansha, S., & Mattoo, S. (2016). Stigma associated with mental illness: Conceptual issues and focus on stigma perceived by the patients with Schizophrenia and their caregivers. Indian Journal of Social Psychiatry, 32(2), 134. doi: 10.4103/0971-9962.181095

Kadri, N., Manoudi, F., Berrada, S., & Moussaoui, D. (2004). Stigma Impact on Moroccan Families of Patients with Schizophrenia. The Canadian Journal of Psychiatry, 49(9), 625–629. doi: 10.1177/070674370404900909

Kane, J. C., Elafros, M. A., Murray, S. M., Mitchell, E. M. H., Augustinavicius, J. L., Causevic, S., & Baral, S. D. (2019). A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries. BMC Medicine, 17(1). doi: 10.1186/s12916-019-1250-8

Kerr, A. N. (2007). Individual Differences Effects on Schizophrenia Stigmatization. PsycEXTRA Dataset. doi: 10.1037/e652972007-001

Kooyman, I., & Walsh, E. (2011). Societal Outcomes in Schizophrenia. Schizophrenia, 644–665. doi: 10.1002/9781444327298.ch31

Lindesay, J. (n.d.). De-stigmatization of elderly people with early- or late-onset Schizophrenia. Psychosis in the Elderly, 123–134. doi: 10.4324/9780203336984_chapter_10

Margetić, B., Aukst-Margetić, B., Ivanec, D., & Filipčić, I. (2008). Perception of Stigmatization in Forensic Patients With Schizophrenia. International Journal of Social Psychiatry, 54(6), 502–513. doi: 10.1177/0020764008090842

Paunović, G., Nenadović, M., Janković, Z., & Vojvodić, P. (2013). 2290 – Sociodemographic characteristics of hospitalized patients with Schizophrenia. European Psychiatry, 28, 1. doi: 10.1016/s0924-9338(13)77149-9

Reddy, D. P. V. (2012). Stigma Among Caregivers/Family Members With Persons of Mental Illness. Paripex – Indian Journal Of Research, 3(1), 165–168. doi: 10.15373/22501991/jan2014/52

Shafti, S. S. (2015). Odyssey of ‘Negative Symptoms’ of Schizophrenia: Rehabilitation vs Stigmatization. Current Psychopharmacology, 4(1), 40–51. doi: 10.2174/2211556004666150918193742

Shrivastava, A., Bureau, Y., & Johnston, M. (2012). Stigma of Mental Illness-1: Clinical reflections. Mens Sana Monographs, 10(1), 70. doi: 10.4103/0973-1229.90181

Sousa, S. D., Marques, A., Rosário, C., & Queirós, C. (2012). Stigmatizing attitudes in relatives of people with Schizophrenia: a study using the Attribution Questionnaire AQ-27. Trends in Psychiatry and Psychotherapy, 34(4), 186–197. doi: 10.1590/s2237-60892012000400004

Urban-Kowalczyk, M., & Kotlicka-Antczak, M. (2019). PLASMA β – ENDORPHIN CONCENTRATION AND SCHIZOPHRENIA ACUTE TREATMENT OUTCOME. doi: 10.26226/morressier.5d1a037a57558b317a1409d4

Wan, K.-F., & Wong, M. M. (2019). Stress and burden faced by family caregivers of people with Schizophrenia and early psychosis in Hong Kong. Internal Medicine Journal, 49, 9–15. doi: 10.1111/imj.14166

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