Malawi Trial Evaluates Stigma Changes Among People Living With Psychosis

A two-arm pilot randomized controlled trial conducted in Blantyre, Malawi, found that mean internalized stigma, anticipated stigma, and experienced stigma decreased over twelve months among people living with psychosis. The investigation, registered under clinical trial identifier NCT06080477, compared a community-based rehabilitation intervention against enhanced usual care. Across the one-year evaluation timeframe, overall stigma measures were generally comparable between participants assigned to the rehabilitation intervention and those receiving enhanced usual care. However, family-enacted stigma was significantly lower at twelve months among participants in the community intervention arm than among participants assigned to usual care, exhibiting a mean difference of -0.97 with a confidence interval between -1.88 and -0.05.

The study sought to examine how stigma dimensions change over time, identify associations between hypothesized predictors and internalized stigma, and evaluate how internalized stigma influences mental health and functional outcomes. While people living with psychosis frequently experience, anticipate, and internalize stigma, the specific predictors and longitudinal outcomes of internalized stigma among patients and their caregivers have remained largely unknown. To address this knowledge gap, the researchers recruited sixty people living with psychosis and 118 caregivers who met study eligibility criteria. Participants completed comprehensive interviewer-administered surveys at baseline, six months, and twelve months.

To evaluate the structural properties of the measurement tools used in the trial, the investigators applied exploratory factor analysis to the stigma scales. This factor analysis supported single-factor structures with adequate internal consistency across most of the assessed stigma scales. Researchers subsequently employed correlation coefficients and adjusted generalized estimating equations to determine longitudinal associations between candidate predictors and internalized stigma outcomes. At baseline, higher family-enacted stigma showed a moderate positive association with higher internalized stigma scores, recorded at a correlation coefficient of 0.34 with a confidence interval ranging from 0.13 to 0.53.

Longitudinal modeling revealed that greater reductions or changes in external stigma measures corresponded to changes in internalized stigma over time. A greater change in family-enacted stigma was weakly associated with a greater change in internalized stigma, yielding an adjusted regression coefficient of 0.24 with a confidence interval of 0.04 to 0.43. Similarly, a greater change in anticipated stigma demonstrated a weak association with a greater change in internalized stigma, showing a regression coefficient of 0.14 with a confidence interval from 0.02 to 0.26.

Baseline assessments indicated that internalized stigma was weakly correlated with psychiatric symptoms among people living with psychosis, showing a correlation coefficient of 0.14 with depressive symptoms and 0.11 with anxiety symptoms. Over the course of twelve months, greater increases in internalized stigma were associated with higher anxiety symptoms, demonstrating an adjusted regression coefficient of 0.13 with a confidence interval of 0.01 to 0.24. Among participating caregivers, internalized stigma also decreased over twelve months, though no evaluated predictors were associated with this change. The authors concluded that anticipated, experienced, and internalized stigma remain prevalent in Malawi, underscoring the need for further research into the underlying mechanisms linking predictors to internalized stigma outcomes.

Subject of Research: Internalized stigma among people living with psychosis and caregivers in Malawi

Article Title: Exploring internalized stigma among people living with psychosis and their caregivers: Insights from a community rehabilitation initiative in Malawi

Article References: Buono, M., Kulisewa, K., Pence, B. W., Gaynes, B. N., Morrison, A. M., Chienda, J., & Stockton, M. A. (2026). Exploring internalized stigma among people living with psychosis and their caregivers: Insights from a community rehabilitation initiative in Malawi. PLOS Mental Health, 3(11), e0000753. https://doi.org/10.1371/journal.pmen.0000753

Image Credits: AI Generated

DOI: 10.1371/journal.pmen.0000753

Keywords: psychosis, internalized stigma, Malawi, community-based rehabilitation, mental health, caregivers, family-enacted stigma, clinical trial, Exploring, internalized, stigma, people