Journal of Marine Medical Society

: 2019  |  Volume : 21  |  Issue : 2  |  Page : 145--150

Relationship between stigma, self-esteem, and quality of life in euthymic patients of bipolar disorder: A cross-sectional study

Debajyoti Bhattacharyya, Anuj Yadav, Arun Kumar Dwivedi 
 Department of Psychiatry, Army College of Medical Sciences, New Delhi, India

Correspondence Address:
Dr. Arun Kumar Dwivedi
Department of Psychiatry, Army College of Medical Sciences, New Delhi


Background: As per the existing literature (mostly Western), bipolar affective disorder or bipolar disorder (BD) is associated with low self-esteem, high stigma, and poor quality of life (QOL). Aims: The current study aimed to assess stigma, self-esteem, and QOL and to examine their interrelationships in euthymic patients of BD in the Indian settings. Settings and Design: This hospital-based, cross-sectional study was conducted in a tertiary care hospital in Delhi over a period of 12 months. Subjects and Methods: Sixty-two adults with BD (as per the International Classification of Diseases-10 criteria) in remission were selected. Stigma, self-esteem, and QOL were assessed using the Internalized Stigma of Mental Illness (ISMI) scale, Rosenberg Self-esteem Rating Scale, and World Health Organization (WHO) QOL-BREF, respectively. Statistical Analysis Used: Data were analyzed using Student's t-test, Pearson's correlation coefficients, and multiple regression model. Results: Thirty-two percent of patients did not experience stigma (ISMI total score < 2.00). Mean total ISMI score for patients was 2.33 (mild stigma). Compared to controls, patients were found to have lower self-esteem (mean: 12.63) and lower scores on WHOQOL-BREF. Self-esteem scores were associated with all domains of WHOQOL-BREF, whereas ISMI total scores were not. Further, self-esteem was not found to be associated with stigma scores. Conclusions: Patients of BD in remission have low self-esteem, experience mild stigma, and have a low QOL. Lower self-esteem was strongly related to lower QOL, whereas stigma was not. Measures to improve self-esteem may benefit patients of BD in the long run.

How to cite this article:
Bhattacharyya D, Yadav A, Dwivedi AK. Relationship between stigma, self-esteem, and quality of life in euthymic patients of bipolar disorder: A cross-sectional study.J Mar Med Soc 2019;21:145-150

How to cite this URL:
Bhattacharyya D, Yadav A, Dwivedi AK. Relationship between stigma, self-esteem, and quality of life in euthymic patients of bipolar disorder: A cross-sectional study. J Mar Med Soc [serial online] 2019 [cited 2022 Jul 2 ];21:145-150
Available from:

Full Text


Bipolar affective disorder, also known as bipolar disorder (BD) and manic-depressive illness, is a major mental disorder characterized by periods of elevated mood and depression.[1] It is the sixth leading cause of disability worldwide and affects about 60 million people.[2] Studies have revealed that majority of patients achieve remission within 6 weeks, though in long-term, they continue to suffer from relapses.[3]

Despite good therapeutic outcomes, individuals diagnosed with BD experience stigma at large. Stigma can be defined as a “mark of disgrace associated with a particular circumstance, quality, or person” (Oxford Dictionary). According to Link and Phelan,[4] stigma consists of five interrelated components: labeling, stereotyping, separation, status loss, and discrimination. The experience of perceived stigma in individuals with mental illness is considered detrimental to recovery.[5] Perceived stigma has been associated with poorer social adjustment and reduced social functioning in people with BD.[6] Internalized stigma can create distress that may precipitate symptoms of BD. Biologically, chronic psychosocial stress caused by stigma may result in inflammatory pathophysiology of BD.[7] Kamaradova et al. in their study reported that self-stigma was an important factor negatively influencing adherence to treatment which may, in turn, affect recovery.[8] Grover et al. in their study concluded that self-stigma was highly prevalent in BD patients in India.[9]

Self-esteem reflects a person's overall self-evaluation of his or her own worth. High self-esteem has been linked to happiness and life satisfaction.[10] Abnormalities of self-esteem is a central feature of BD, being high in mania and low in depression. It has been observed that abnormalities of self-esteem persist after remission. Euthymic bipolar patients in remission had significantly lower self-esteem than the controls which was described as feeling “more distant to others,” as reported by Himmighoffen et al.[11] It was also noted that at any point of illness, symptoms of depression and mania are significantly related to fluctuations in low mood and self-esteem.[12] Knowles et al. (2007) found that the instability of self-esteem is present among BD patients in remission.[13]

Good quality of life (QOL) encompasses more than just good health. The World Health Organization (WHO) has described QOL as “individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.”[14] Depending on the severity of illness in the long run, poor QOL has been shown to be associated with unemployment, lost productivity, poor social functioning, disability, marital failure, and high treatment costs.[15] Increasingly, health-care professionals are recognizing the fact that measures of diseases alone are insufficient determinants of health status or outcomes. In addition to the objective measures of remission, sustained remission, and recovery, subjective measures of health and well-being are increasingly being incorporated in the outcome measures, and QOL is one such subjective measure. Although a relatively large body of research has addressed the relationship between QOL and unipolar major depressive disorder,[16] research into QOL in bipolar affective disorder has been scarce,[17] despite expert opinion that improving functioning, and QOL is a key treatment goal in this patient population.[18]

Literature suggests that BD has generally been associated with stigma, poor QOL, and low self-esteem. Mashiach-Eizenberg et al. in their study proposed a model whereby internalized stigma is assumed to affect recovery and QOL, mediated through hope and self-esteem in serious mental illness.[19] Similar findings were reported in other studies too.[20] Various studies on BD patients have noted this interplay between stigma, self-esteem, and QOL.[21]

As there is limited data from India on this significant issue, it was proposed that both self-esteem and sense of stigmatization in euthymic patients with BD would be worth investigating. The purpose of the study was to investigate the relationship between stigma, self-esteem, and QOL in remitted cases of BD and to compare them with healthy controls in the Indian population.

 Subjects and Methods

This hospital-based, cross-sectional study intended to assess the stigma, self-esteem, and QOL and thereby to examine their interrelationship in euthymic patients of BD and to compare them with controls. The study was conducted in the department of psychiatry of a tertiary care hospital in North India, over a period of 12 months (September 01, 2015–August 31, 2016). Those consenting patients of BD more than 18 years of age, who were in remission, (Young Mania Rating Scale [YMRS] score <4 and Hamilton Depression Rating Scale [HDRS] score <7) diagnosed as per the International Classification of Diseases-10 diagnostic criteria for research, and with or without medication, were selected for the study. Although euthymic states were mainly assessed by history taking and mental status examination, lower cutoff scores of YMRS and HDRS in the current study compared to those used in other studies, were likely to ensure higher sensitivity that the illness had no role in the outcome measures of stigma and self-esteem. Those patients who had history of chronic physical illnesses, other mental illness, subclinical depression, organic brain syndromes, and substance abuse/dependence were excluded from the study. Age- and sex-matched healthy controls were recruited. Sample size was calculated with appropriate statistical method. Statistical formula for cross-sectional study (n = Z2 P[1 −P]/d2) was applied, where n is the sample size, Z is the level of confidence, P is expected prevalence (taken as 2%[22]), and d is precision (corresponding to effect size, d = 0.05, at 95% precision). The level of confidence usually aimed for is 95% (confidence interval). The required sample size for the study was a minimum of 31 cases. Sixty-two cases were recruited for the current study.

After obtaining informed consent from the patients, the entire data collection from one patient was completed in a single session. A semi-structured proforma was used to record sociodemographic data. Euthymic status of patients was assessed using YMRS and Hamilton Rating Scale for Depression. Stigma, self-esteem, and QOL were assessed using the Internalized Stigma of Mental Illness (ISMI) scale, Rosenberg Self-esteem Rating Scale, and WHOQOL-BREF, respectively. Internal consistency reliability of the full-scale score of ISMI ranges from 0.80 to 0.92. It is considered to be reliable and valid for use across a wide range of settings, disorders, and cultures.[23] Rosenberg Self-Esteem Scale (RSES) (Rosenberg, 1965, 1979) demonstrates a Guttman scale coefficient of reproducibility of 0.92, indicating excellent internal consistency. Test–retest reliability over a period of 2 weeks reveals correlations of 0.85 and 0.88, indicating excellent stability.[24] The scale has been used with a variety of groups including adults. WHOQOL-BREF has acceptable reliability and validity. Domain scores of WHOQOL-BREF show high correlation (0.89 or above) with WHOQOL-100 domain scores. WHOQOL-BREF domain scores show good discriminant validity, content validity, internal consistency, and test–retest reliability. As such, WHOQOL-BREF has been recommended as a valid tool to measure QOL in clinical settings as well as research.[14]

The clearance was obtained from the Institutional Ethics Committee and Scientific Committee before starting the study. All scales were in English and their Hindi translation (developed by the faculty group discussion followed by translation–retranslation technique) was also used for those who could not understand English. A trained psychiatry resident assisted the patients in making the appropriate responses for data collection. Patients had been regularly followed up and treated with pharmacotherapy and psychosocial interventions as usual. Confidentiality was ensured. Patients were free to drop out of the study at any time.

Data analysis was performed using SPSS version 20 (IBM Corp, New York, USA). Chi-square and Student's t-test were used to compare groups on various parameters. Multivariate analysis (multiple linear regression) was carried out to find the association of RSES, ISMI, and QOL scores in BD patient group.


Mean age of patients was 34.44 years (standard deviation [SD] = 10.83). Among the study patients, 72.6% were male, majority (58.1%) studied till the 12th standard, and 93.5% were married. There were no significant differences in demographic variables between the patients and controls [Table 1]. Mean duration of illness was 6.94 years (SD = 6.01, median: 5, and range: 1–28) and mean number of relapses was 1.1 (SD = 1.33, median: 1, and range: 1–4).{Table 1}

ISMI mean total score of patients was 2.33 (SD = 0.56) (mild stigma). Of the patients, 35.5% (22) experienced moderate-to-severe stigma, whereas 32.2% (20) experienced no stigma on total ISMI score. Most patients did not feel alienation except for graduates (mean = 2.34) having mild stigma in this subscale. Discrimination score showed that all patients felt discriminated; females (mean = 2.66, moderate stigma) felt more discriminated than males. Discrimination was highest in the unemployed (mean = 2.71) and graduates (mean = 2.76). Graduates also felt severe stigma in social withdrawal subscale, and their scores were high in all subscales with highest mean (3.40) in stereotype subscale. Uneducated patients felt severe stereotype stigma (mean = 3), whereas on all other subscales, they experienced mild-to-moderate stigma.

RSES mean score for cases was 12.63, which is lower than the normal score (15) and was significantly lower than controls (24.39) (P < 0.001). WHOQOL-BREF mean score of patients in all domains was significantly lower than controls [Table 2]. [Table 3] shows correlation between RSES, ISMI, and WHOQOL-BREF scores. RSES score showed significant negative correlation with ISMI (discrimination domain) (r = −0.28, P < 0.05) and positive correlation with all domains of WHOQOL-BREF. ISMI (discrimination) scores correlated negatively with WHOQOL-BREF D1 physical health and D4 environment domains. ISMI (alienation) scores correlated negatively with WHOQOL-BREF D3 social relation domain. ISMI (total) scores correlated only with WHOQOL-BREF D2 psychological health domain.{Table 2}{Table 3}

A stepwise regression analysis was conducted with the four domains of WHOQOL-BREF as dependent variables and ISMI subscales and RSES as the independent variables. Only RSES was found to be significantly associated with WHOQOL-BREF in all domains [Table 4]. ISMI (stigma resistance) was associated with WHOQOL-BREF D1 physical health domain explaining 51% of the variance (F = 4.10, df = 6, P < 0.001, adjusted R2 = 0.51), whereas ISMI (social withdrawal) score (β = −0.27, P < 0.05) was associated with WHOQOL-BREF environment domain explaining 33.4% of the variance (F = 6.38, df = 6, P < 0.001, adjusted R2 = 0.33).{Table 4}


In our study, we have found that patients of BD in remission experienced mild stigma. It may be noted that these patients belonged to an urban background and had better access to health-care facilities since the study was conducted in a metro city (New Delhi). Compared to controls, they experienced lower self-esteem and lower QOL. However, QOL was associated only with scores of self-esteem. There was only a limited association of stigma with QOL, in that stigma (resistance) was associated with physical health and stigma (social withdrawal) was associated with QOL in the environment domain. Stigma was not significantly associated with self-esteem.

According to Picco et al., stigma was shown to be negatively correlated with self-esteem and high stigma was associated with reduced self-esteem scores and poorer QOL.[25] Another recent study by Huang et al. on patients of Schizophrenia revealed that the QOL was associated with both self-esteem (positively) and stigma (negatively).[26] Our results do not conform to these findings.

Michalak et al. in their study on high-functioning BD patients concluded that the diagnostic label of BD did not necessarily lead to stigma, and many patients were managing well.[27] About one-third of our patients in the current study did not experience stigma and another one-third experienced mild stigma (ISMI total score); our findings are in line with those of Michalak et al.

Mashiach-Eizenberg et al. in their study on patients with serious mental illnesses concluded that self-esteem mediates the relationship between stigma and QOL and that effects of internalized stigma on QOL may be closely related to levels of self-esteem.[19] In our study, we have found that patients had lower QOL than controls, and self-esteem was associated with QOL, as evidenced by the results of regression analysis. While many patients in this study did not experience significant stigma, all patients had low self-esteem and lower QOL. Although we did not perform mediation analysis, our findings are in line with Michalak et al. with respect to the importance of self-esteem.

Lower number of females in the study may be either due to a bias in sampling or lower utilization of mental health services by females. Most of the patients were educated. A shorter mean duration of illness and lower number of relapses in the present study as compared to other studies may be due to early detection and treatment of patients in the study population since better health services are available to them.

All patients had low self-esteem. A lower score in females points to the possible difficulties that they may be facing. Higher self-esteem score in the employed patients is an expected outcome, as being gainfully employed is known to boost self-worth and productivity. The negative correlation between ISMI (total) score and WHOQOL-BREF psychological health domain suggests that higher the stigma, lower is the satisfaction in life. Further, the analysis of ISMI subscale correlations reveals that those patients who felt socially isolated were more likely to experience poor QOL in terms of social relations.

Oliviera et al. (2016) in their study proposed a model in which self-esteem mediates the effects of internalized stigma over QOL and have recommended that increasing self-esteem in patients with severe mental illnesses may be the key to improving their QOL.[28] From the current study, we know that self-esteem definitely has a role in improving the QOL, but whether it is through stigma, is not clear, as in the current study we did not find stigma significantly associated with lower QOL. Furthermore, we can conclude from our study results that stigma is not significantly related to self-esteem either.

The study was of a correlational nature whereas causality can be better assessed with a longitudinal study design. This may be one of the limitations. The study was carried out in an urban setting, and most patients belonged to urban areas where they have easy accessibility to quality health care. Hence, the results may not be generalizable to rural community settings. Results of the study emphasize the importance of stigma and self-esteem in BD patients and underline their role in the long-term management of patients with the disorder. Interventions targeted at enhancing the self-esteem of BD patients in remission are likely to improve QOL and prevent relapses, thereby helping in better long-term management. Interventions targeted at reducing stigma may have a lesser effect since self-esteem appears to be an independent variable affecting QOL.


In BD patients, compared to controls, self-esteem was found to be much lower and was noted to be associated with a lower QOL, whereas stigma was not found to have a significant relationship with QOL. Although two subscales of stigma were associated with two domains of QOL, it was not related as strongly as self-esteem which showed significant association in all domains. It may be inferred that self-esteem is the key to improving QOL in remitted BD patients. Prospective studies in future may be undertaken to further refine this concept. Measures to boost self-esteem in BD patients may bring about a positive change in their lives by maintaining sustained recovery and personal functioning, thereby improving QOL.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Anderson IM, Haddad PM, Scott J. Bipolar disorder. BMJ 2012;345:e8508.
2Schmitt A, Malchow B, Hasan A, Falkai P. The impact of environmental factors in severe psychiatric disorders. Front Neurosci 2014;8:19.
3Tohen M, Zarate CA Jr., Hennen J, Khalsa HM, Strakowski SM, Gebre-Medhin P, et al. The McLean-Harvard first-episode mania study: Prediction of recovery and first recurrence. Am J Psychiatry 2003;160:2099-107.
4Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol 2001;27:363-85.
5Lazowski L, Koller M, Stuart H, Milev R. Stigma and Discrimination in People Suffering with a Mood Disorder: A Cross-Sectional Study. Depression Research and Treatment; 2012. Available from: [Last accessed on 2018 Mar 22].
6Perlick DA, Rosenheck RA, Clarkin JF, Sirey JA, Salahi J, Struening EL, et al. Stigma as a barrier to recovery: Adverse effects of perceived stigma on social adaptation of persons diagnosed with bipolar affective disorder. Psychiatr Serv 2001;52:1627-32.
7Levy B, Tsoy E, Brodt M, Petrosyan K, Malloy M. Stigma, social anxiety, and illness severity in bipolar disorder: Implications for treatment. Ann Clin Psychiatry 2015;27:55-64.
8Kamaradova D, Latalova K, Prasko J, Kubinek R, Vrbova K, Mainerova B, et al. Connection between self-stigma, adherence to treatment, and discontinuation of medication. Patient Prefer Adherence 2016;10:1289-98.
9Grover S, Hazari N, Aneja J, Chakrabarti S, Avasthi A. Stigma and its correlates among patients with bipolar disorder: A study from a tertiary care hospital of North India. Psychiatry Res 2016;244:109-16.
10Furnham A, Cheng H. Lay theories of happiness. J Happiness Stud 2000;1:227-46.
11Himmighoffen H, Budischewski K, Härtling F, Hell D, Böker H. Self-esteem and partner relationships of patients with bipolar affective disorder: A study of the interval personality with the Giessen-test. Psychiatr Prax 2003;30:21-32.
12Pavlickova H, Varese F, Smith A, Myin-Germeys I, Turnbull OH, Emsley R, et al. The dynamics of mood and coping in bipolar disorder: Longitudinal investigations of the inter-relationship between affect, self-esteem and response styles. PLoS One 2013;8:e62514.
13Knowles R, Tai S, Jones SH, Highfield J, Morriss R, Bentall RP. Stability of self-esteem in bipolar disorder: Comparisons among remitted bipolar patients, remitted unipolar patients and healthy controls. Bipolar Disord 2007;9:490-5.
14Skevington SM, Lotfy M, O'Connell KA; WHOQOL Group. The World Health Organization's WHOQOL-BREF quality of life assessment: Psychometric properties and results of the international field trial. A report from the WHOQOL group. Qual Life Res 2004;13:299-310.
15Miller S, Dell'Osso B, Ketter TA. The prevalence and burden of bipolar depression. J Affect Disord 2014;169 Suppl 1:S3-11.
16Angermeyer MC, Holzinger A, Matschinger H, Stengler-Wenzke K. Depression and quality of life: Results of a follow-up study. Int J Soc Psychiatry 2002;48:189-99.
17Ellison N, Mason O, Scior K. Bipolar disorder and stigma: A systematic review of the literature. J Affect Disord 2013;151:805-20.
18Sachs GS, Rush AJ. Response, remission, and recovery in bipolar disorders: What are the realistic treatment goals? J Clin Psychiatry 2003;64 Suppl 6:18-22.
19Mashiach-Eizenberg M, Hasson-Ohayon I, Yanos PT, Lysaker PH, Roe D. Internalized stigma and quality of life among persons with severe mental illness: The mediating roles of self-esteem and hope. Psychiatry Res 2013;208:15-20.
20Yanos PT, Roe D, Lysaker PH. The impact of illness identity on recovery from severe mental illness. Am J Psychiatr Rehabil 2010;13:73-93.
21Hayward P, Wong G, Bright JA, Lam D. Stigma and self-esteem in manic depression: An exploratory study. J Affect Disord 2002;69:61-7.
22Merikangas KR, Jin R, He JP, Kessler RC, Lee S, Sampson NA, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry 2011;68:241-51.
23Boyd JE, Adler EP, Otilingam PG, Peters T. Internalized stigma of mental illness (ISMI) scale: A multinational review. Compr Psychiatry 2014;55:221-31.
24Rosenberg M. Society and the Adolescent Self-Image. Princeton: Princeton University Press; 2015.
25Picco L, Pang S, Lau YW, Jeyagurunathan A, Satghare P, Abdin E, et al. Internalized stigma among psychiatric outpatients: Associations with quality of life, functioning, hope and self-esteem. Psychiatry Res 2016;246:500-6.
26Huang WY, Chen SP, Pakpour AH, Lin CY. The Mediation Role of Self-Esteem for Self-Stigma on Quality of Life for People With Schizophrenia: A Retrospective Longitudinal Study. Journal of Pacific Rim Psychology. Cambridge University Press; 2018;12:e10.
27Michalak E, Livingston JD, Hole R, Suto M, Hale S, Haddock C. It's something that I manage but it is not who I am': Reflections on internalized stigma in individuals with bipolar disorder. Chronic Illn 2011;7:209-24.
28Oliveira SE, Carvalho H, Esteves F. Internalized stigma and quality of life domains among people with mental illness: The mediating role of self-esteem. J Ment Health 2016;25:55-61.