People with bipolar disorder who have lost a family member to suicide may carry a heavier psychological burden than their diagnosis alone explains. A new cross-sectional study from a specialized mood disorders clinic in Türkiye reports that, among 97 euthymic outpatients with bipolar disorder, a family history of death by suicide was independently associated with higher internalized stigma—the process by which individuals absorb social prejudice about mental illness and turn it against themselves. The finding, published in Frontiers in Psychiatry, emerged from a multiple linear regression analysis in which the association persisted after adjustment for age, illness duration, number of mood episodes, self-esteem, and several sociodemographic variables.
The study, conducted by researchers affiliated with Kocaeli University Research and Application Hospital and collaborating institutions, set out to measure internalized stigma during the euthymic phase—periods of relative symptom stability—and to identify the individual, familial, and clinical factors associated with it. Participants were diagnosed according to DSM-5 criteria and had maintained clinical stability for at least six months, defined as continuous outpatient follow-up without changes in medication. On the assessment day, specialist psychiatrists verified euthymia using the Young Mania Rating Scale and the Hamilton Depression Rating Scale, with mean scores of 0.71 and 1.96 respectively, confirming that the sample was genuinely stable at the time of testing.
Each participant completed three validated self-report instruments: the Internalized Stigma of Mental Illness Scale (ISMI), a 29-item questionnaire covering alienation, social withdrawal, perceived discrimination, and stigma resistance; the Resilience Scale for Adults (RSA); and the Rosenberg Self-Esteem Scale (RSES) in its Turkish Guttman-scored version, in which higher scores indicate lower self-esteem. Clinicians also recorded sociodemographic details, lifetime hospitalizations, and the total number of mood episodes, cross-referenced against the hospital’s electronic medical records. The authors caution that because episode history was assessed retrospectively, episode counts should be read as approximate indicators of lifetime illness burden rather than precise tallies—hypomanic episodes, in particular, could not be consistently verified and were not counted separately.
The headline numbers paint a picture of a chronic, burdensome illness course. Participants had a mean illness duration of nearly 16 years, a mean age of onset of about 25 years, an average of 5.47 mood episodes, and 2.58 hospitalizations. Roughly one-third reported a family history of any psychiatric disorder, one-fifth reported a family history of death by suicide, and a similar proportion reported a personal history of suicide attempts. The mean ISMI total score was 55.68, with a mean item score of 1.93, indicating low-to-moderate internalized stigma overall. Using the commonly applied cut-off of 2.5 for the mean item score, 13.4 percent of participants—13 individuals—fell into the moderate-to-high stigma category.
In preliminary bivariate comparisons, the moderate-to-high stigma group differed from the low-stigma group on several measures that survived correction for multiple comparisons using the Benjamini–Hochberg false discovery rate procedure. Those with higher stigma were older (mean age 50.08 versus 39.67 years), had longer illness duration (26.69 versus 14.32 years), and had experienced more mood episodes (8.38 versus roughly 5). A family history of death by suicide was markedly more common in the high-stigma group, present in 61.5 percent versus 14.3 percent of the low-stigma group. The largest differences appeared on the psychological measures: the high-stigma group had substantially lower resilience scores (96.92 versus 131.24) and higher RSES scores, indicating lower self-esteem. The authors emphasize that, given the small size of the high-stigma group, these bivariate results should be treated as exploratory rather than confirmatory.
The main analysis, a multiple linear regression with the ISMI total score as the dependent variable, told a more nuanced story. The overall model was statistically significant and explained 52 percent of the variance in stigma scores, although repeated 5-fold cross-validation showed attenuation to a mean cross-validated R² of 0.372, indicating that the apparent fit was somewhat optimistic. Within the model, psychological resilience showed the strongest independent association with internalized stigma (standardized β = –0.392, p < 0.001), with higher resilience linked to lower stigma. Higher educational attainment was also associated with lower stigma (β = –0.185, p = 0.029), while a family history of death by suicide was associated with higher stigma (β = 0.203, p = 0.019). The total number of mood episodes showed a borderline positive association (β = 0.180, p = 0.050). Age, illness duration, self-esteem, gender, marital status, and place of residence were not significantly associated in the final model.
Sensitivity analyses added important caveats. When the regression was re-estimated using 5,000 bootstrap resamples with bias-corrected and accelerated confidence intervals, the inverse association with resilience proved the most stable. The estimate for family history of death by suicide remained positive, but its confidence interval was wide, spanning from near the null value upward, and the authors note that the precision and stability of this estimate should be interpreted cautiously. The bootstrap analysis also supported a positive association with age, which had only narrowly missed significance in the conventional model—a discrepancy the authors attribute to analytic sensitivity and sampling variability. In an additional age-adjusted analysis of covariance, participants with a family history of death by suicide had significantly higher ISMI total scores than those without, with an adjusted mean difference of 9.60 points.
Why might a familial suicide death shape stigma in bipolar disorder? The authors draw on the broader suicide bereavement literature, which documents that family members bereaved by suicide frequently report shame, blame, social judgment, avoidance, and secrecy. In sociocultural contexts where mental illness is experienced within the family system rather than purely individually, stigma may extend to relatives through associative or familial stigma. The authors also note that a family history of suicide in bipolar disorder marks a more severe clinical phenotype, associated with earlier onset, more comorbidities, and higher personal suicide risk. They hypothesize that this dual burden—a more severe illness course alongside the psychosocial weight of bereavement—may contribute to internalized stigma, and that stigma-related shame might promote treatment avoidance. Crucially, they stress that these psychosocial mechanisms were not directly measured in the study and remain hypotheses for future research rather than empirically tested pathways.
The relatively low overall stigma levels in the sample likely reflect its composition. Participants were predominantly urban, relatively highly educated, and under long-term regular follow-up at a specialized tertiary-care mood disorders unit offering pharmacotherapy, psychotherapy, and routine psychoeducation. The authors explicitly caution that because different care settings were not directly compared, no protective effect of specialized clinic follow-up on stigma can be inferred from these findings. Other limitations are substantial: the cross-sectional design precludes causal inference; the sample came from a single center in one city; family history relied on self-report, which may introduce recall bias; and the small high-stigma subgroup limits statistical power. Internalized stigma was also measured only during euthymia, which may underestimate the burden experienced during depressive or manic episodes, and the stable, treatment-engaged sample may represent a selection bias toward more favorable psychosocial outcomes.
Despite these caveats, the authors argue the findings carry practical weight. Because a family history of death by suicide is not itself modifiable, it can instead serve as a marker helping clinicians identify individuals who may benefit from closer follow-up, suicide-focused psychoeducation, and additional psychosocial support targeting stigma-related vulnerability. The strong and stable association with resilience—potentially a modifiable psychological resource—suggests that resilience-building components, such as psychoeducation and cognitive techniques, could be usefully integrated into anti-stigma interventions. The association with educational attainment points toward longer-term strategies, including supporting young people affected by bipolar disorder to stay engaged with education. The authors conclude that systematic assessment of family suicide history during clinical interviews, combined with efforts to strengthen resilience and health literacy, may represent vital targets for reducing the internalized burden carried by people living with bipolar disorder, while emphasizing that longitudinal studies are needed to substantiate the proposed mechanisms.
Subject of Research: Internalized stigma and its individual, familial, and clinical correlates in euthymic bipolar disorder
Article Title: Intergenerational burden: deconstructing the dual impact of familial suicide in a specialized bipolar clinic, from clinical risk to internalized stigma
Article References: Kocaayan, F. S., Şişman, E., Atasoy Kaplan, H., Dalkıran, İ., Yılmaz Abaylı, H., & Polat, A. (2026). Intergenerational burden: deconstructing the dual impact of familial suicide in a specialized bipolar clinic, from clinical risk to internalized stigma. Frontiers in Psychiatry, 17, Article 1931254. https://doi.org/10.3389/fpsyt.2026.1931254
Image Credits: AI Generated
DOI: 10.3389/fpsyt.2026.1931254
Keywords: bipolar disorder, internalized stigma, family history of suicide, psychological resilience, euthymia, cross-sectional study, ISMI scale, self-esteem, mood episodes, suicide bereavement, psychoeducation, Frontiers in Psychiatry
News Source: Glenn Wilkins. (October 28, 2026). Family History of Suicide Linked to Higher Internalized Stigma in Euthymic Bipolar Disorder. Scienmag.
