Uncovering the Role of Self-Stigma in Clinical Depression

Self-stigma has long been a subject of curiosity for me, both in my clinical work and my own life experience. There is a significant body of literature focusing on mental health stigma in its many forms—whether internalized, perpetuated by the public, or baked into the system itself. As the classic horror movie line goes, “The call is coming from inside the house.”

Pangs for the Memories

Stigma is intimately related to shame and guilt, those pangs of sharp emotional pain as well as the dull, persistent aches that can linger for years. Internalized stigma is a key concept not only in mental health but also in other realms where we see internalized -isms: internalized racism, misogyny, antisemitism, anti-Asian bias, ableism, and a host of other cultural polarities. These all serve to undermine the foundation of a healthy sense of self, quietly eroding self-worth from within—while also reinforcing societal stigma and driving intergenerational transmission of hatred.

It is worth noting that research on self-stigma in psychiatry has traditionally focused more on schizophrenia, related psychotic conditions, and bipolar disorder. These are diagnoses that, for complex reasons, tend to attract more public stigma. And while it seems almost self-evident that self-stigma would play a critical role in other conditions—major depressive disorder (MDD), anxiety disorders, PTSD, OCD, ADHD, and more—there has been less research in these domains. The reasons for this gap aren’t entirely clear. I wonder if it’s because professionals find it easier to study conditions where external stigma is more readily apparent, or perhaps those ostensibly “more severe” disorders are easier to study for defensive reasons, being less personally relatable to those in the profession.

Studying Self-Stigma, Empowerment and Major Depressive Disorder

A recent study in the Journal of Affective Disorders (Lasalvia et al., 2025) addresses this gap by examining self-stigma in clinical depression, with a particular focus on empowerment—a concept closely intertwined with classic depression symptoms such as low self-esteem, shame, and guilt. Empowerment, in this context, is associated with better engagement in treatment, increased self-efficacy, and improved overall well-being.

The researchers conducted a cross-sectional study involving people across 34 countries with a diagnosis of major depressive disorder, reportedly as part of the ASPEN/INDIGO-Depression project. They evaluated empowerment, self-esteem, and self-stigma using standardized instruments: the Boston University Empowerment Scale (BUES) for empowerment, the Rosenberg Self-Esteem Scale (RSES) for self-esteem, and the Internalized Stigma of Mental Illness (ISMI) scale for self-stigma. Data were collected from 1,058 participants. To incorporate a cultural lens, they also examined correlations with the United Nations Human Development Index, which measures a country’s overall population health and longevity, education, and standard of living.

The authors highlight several key points that frame their study. First, they clarify that the internalization of self-stigma from public and structural sources occurs in three stages: (1) being aware of mental health stereotypes, (2) accepting these stereotypes as true, and (3) identifying with and applying these stereotypes to oneself. They note that self-stigma comes with a host of risks, serving as a significant barrier to health and personal growth. People with high self-stigma may delay seeking care, stop treatment prematurely, have a higher likelihood of discontinuing necessary medications, and report lower levels of life satisfaction.

Self-Stigma

Self-stigma undermines self-esteem through hostile self-attributions and makes dysfunctional behavior in work and relationships more likely. Its intensity and impact can vary across cultures. Perhaps most crucially, self-stigma and clinical depression drive one another in a vicious circle, consolidating negative self-schemas and leading to entrenched, unconstructive ways of living. Higher self-esteem, by contrast, is associated with resilience, a sense of personal worth, and motivation. It drives self-efficacy and supports recovery. When self-esteem is low, it undermines confidence and functioning in daily life, including the capacity for self-care.

Empowerment

Empowerment, the study’s other major focus, is widely recognized as a cornerstone of mental health recovery. Empowerment, as described by the study authors, enhances one’s sense of personal control (what psychologists call an “internal locus of control”), boosts confidence in decision-making—including the ability to stick with treatment—and is linked to a suite of qualities such as hope, optimism, and self-advocacy.

In psychoanalytic terms, empowerment, self-esteem, absence of stigma, and the capacity to direct one’s own treatment can be thought of as forming a healthy, effective stance toward one’s developmental needs—what Bion (1962) described as “the psychoanalytic function of the personality.”

Findings

Results showed that self-stigma had a significant negative effect on empowerment, both directly and indirectly via reduced self-esteem. These relationships held true even after controlling for other variables. Importantly, MDD was associated with increased self-stigma; 42 percent of participants reported elevated self-stigma, demonstrating that self-stigma is not limited to more stigmatized conditions like schizophrenia and bipolar disorder, but is also highly relevant to clinical depression—a condition that is often more familiar and socially accepted.

Mental Health Stigma Essential Reads

Why Silence Is Clinically Dangerous

When Humor Helps—and Hurts—in the Face of Stigma

The study also observed that the relationship between self-stigma, empowerment, and self-esteem was consistent across countries with different levels of human development, though the degree of self-stigma did vary somewhat with cultural context. Notably, among participants from areas with a higher development index, the deleterious impact of self-stigma was stronger. This suggests that while culture shapes the experience, the basic pattern is robust–and that broad social measures are needed to reduce public and structural stigma.

Implications

While more longitudinal research is needed, this study strongly suggests that self-stigma is a significant recovery factor for people with major depression. Self-stigma may lead to reduced empowerment, which can interfere with treatment success. As such, psychotherapeutic and supportive approaches—including peer-led programs—which identify and address self-stigma may provide added benefit by improving self-esteem, self-efficacy, and empowerment, and ultimately increasing access to care. These need to be tested in follow-up research, but are intuitively sound. By addressing self-stigma, we can help restore developmental strivings that both self-stigma and clinical depression undermine.

It’s important to remember that depression in particular affects not just mood, but also energy and motivation, decision-making, self-worth, hope, and one’s sense of the future. It often leads to social withdrawal and persistent feelings of guilt and shame, especially around the perception of being a burden to others. These dynamics not only push proper care just out of reach, but can also contribute to long-term physical health problems, and—when suicide is a factor—tragically lethal outcomes.

Paying attention to self-stigma, which by its very nature tends to remain hidden and elusive, is critically important—regardless of the specific clinical context. As part of the broader arc of human development, recognizing if we have internalized negative stereotypes about our own identities, and putting into words the ways in which this shapes our perspectives and actions, is a worthwhile and often transformative endeavor.

However, doing so can be emotionally and psychologically stressful, requiring a certain level of preparation. Cultivating resilient practices, including self-compassion, can help set the stage for such self-appraisal. If the process becomes more challenging, seeking professional assistance may be helpful. On a societal level, public recognition and remedy for externalized forms of stigma is vital—not just for individuals, but for the well-being of our communities as a whole.