Internalised stigma, social functioning and quality of life in severe mental disorders: the moderating role of social support

Introduction and objective:Internalised stigma is a pervasive phenomenon in individuals with severe mental disorders and is associated with reduced self-esteem, social withdrawal, and impaired recovery trajectories. Previous literature suggests that stigma adversely affects quality of life both directly and indirectly through diminished social functioning. Social support has been proposed as a potential buffering factor that may attenuate these negative effects across different illness contexts. However, the interplay between stigma, functioning, and support remains insufficiently clarified, particularly within integrated mediation–moderation frameworks. This study aimed to examine the mediating role of social functioning in the relationship between internalised stigma and quality of life, and to test whether perceived social support moderates these associations.

Methods

This cross-sectional study was conducted between April 2023 and April 2024 in the psychiatry outpatient clinics of two university hospitals. Eighty patients diagnosed with schizophrenia (52.5%) or bipolar disorder (47.5%) according to DSM-5 criteria and confirmed to be in remission were included. Data were collected using the Quality of Life Scale, WHO Quality of Life-BREF (8-item version), Functioning Assessment Short Test, Internalised Stigma of Mental Illness Scale, and Multidimensional Scale of Perceived Social Support. Statistical analyses were performed using Jamovi and SPSS (PROCESS Macro v4.2). Group comparisons, correlation analyses, and multiple linear regression models were conducted. Mediation and moderated mediation effects were tested using Hayes’ Model 8 and Model 59 with bootstrapped confidence intervals.

Results

Participants had a mean age of 39.39±11.31 years, and the majority were male (71.3%) and unemployed (68.8%). Quality of life (60.03±17.71) and perceived social support (55.99±15.78) were at moderate levels, whereas internalised stigma (58.42±16.08) was moderate and functional impairment was mild (0.97±0.64). Quality of life was negatively correlated with internalised stigma and functional impairment, and positively correlated with social support (p<0.001). In regression analyses, the model predicting general quality of life explained 56% of the variance (R²=0.564, p<0.001), with internalised stigma (β=-0.398) and functional impairment (β=-0.356) as significant negative predictors. In contrast, disease-specific quality of life was primarily predicted by functional impairment (β=-0.405) and social support (β=0.372; R²=0.383, p<0.001). Moderated mediation analyses showed that perceived social support did not exert a significant moderating effect on any pathway (p>0.05). However, social functioning demonstrated a consistent and statistically robust mediating role across all levels of social support, indicating that stigma indirectly reduced quality of life through its detrimental effect on functioning.

Conclusions

Internalised stigma is a key determinant of reduced quality of life in severe mental disorders, primarily through its impact on social functioning. Although social support is positively associated with disease-specific quality of life, it does not significantly buffer the negative effects of stigma within this causal pathway. These findings suggest that interventions solely targeting social support may be insufficient. Instead, comprehensive psychosocial rehabilitation strategies addressing both stigma reduction and functional recovery are required to improve long-term patient outcomes.

References

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