Klinik Araştırma
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The Relationship between Internalized Stigma, Perceived Social Support and Self-Efficacy in Bipolar Disorder

Yıl 2022, Cilt: 32 Sayı: 3, 350 - 357, 01.08.2022
https://doi.org/10.54005/geneltip.1104022

Öz

Objectives: Many people with mental illness are subject to social and objective exclusion, discrimination, and stigma. One of the mental illnesses most exposed to stigma is bipolar disorder (BD). This study aimed to ascertain patient perceptions of social support and examine the association between internalized stigma, self-esteem, and clinical course in patients with bipolar disorder.
Method: This cross-sectional study enrolled 103 patients with BD. Sociodemographic form, Internalized Stigma of Mental Illness Inventory (ISMI), Rosenberg Self-Esteem Scale (RSE), Multidimensional Scale of Perceived Social Support (MSPSS) were used to collect data in this study.
Results: The mean age of 103 patients with BD was 40,67±10,53. 46 (44.7%) of these participants were female. The ISMI score was higher in patients who were unemployed than in those who were employed (p=0.050). In terms of ISMI scores, those with residual symptoms had significantly higher scores than those without (p=0,001). The ISMI scores of those whose medication was inconsistent were significantly higher than those who were compliant with their medication (p=0.004). ISMI had a positive correlation between the number of depressions (p<0.001; r=0.243); medication non-adherence (p<0.001; r=0.282). ISMI had negative correlation between RSE (r=-0.711; p<0,001); MSPSS (r=-0,384; p<0,001). In multivariate linear regression, internalized stigma was significantly higher among those with low self-esteem, those who reported a lower level of social support from their friends, and those with residual symptoms.
Conclusions: The link between stigma, self-esteem, and social support, and their effects on patients with BD, have important implications for psychiatric care. Direct interventions to reduce the negative effects of stigma in BD deserve clinical attention as they may potentially improve outcomes.

Teşekkür

The authors would like to thank all patients and controls for participating in this study.

Kaynakça

  • 1. Huggett C, Birtel MD, Awenat YF, et al. A qualitative study: experiences of stigma by people with mental health problems. Psychol Psychother. 2018;91:380-97.
  • 2. Rusch N, Angermeyer MC, Corrigan PW. Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. Eur Psychiatry. 2005;20:529-39.
  • 3. Corrigan PW, Rao D. On the self-stigma of mental illness: stages, disclosure, and strategies for change. Can J Psychiatry. 2012;57:464-9.
  • 4. Rusch N, Corrigan PW, Todd AR, Bodenhausen GV. Implicit self-stigma in people with mental illness. J Nerv Ment Dis. 2010;198:150-3.
  • 5. Clement S, Schauman O, Graham T, et al. What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychol Med. 2015;45:11-27.
  • 6. Pal A, Sharan P, Chadda RK. Internalized stigma and its impact in Indian outpatients with bipolar disorder. Psychiatry Res. 2017;258:158-65.
  • 7. Post F, Pardeller S, Frajo-Apor B, et al. Quality of life in stabilized outpatients with bipolar I disorder: Associations with resilience, internalized stigma, and residual symptoms. J Affect Disord. 2018;238:399-404.
  • 8. Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Soc Sci Med. 2010;71:2150-61.
  • 9. Alonso M, Guillen AI, Munoz M. Interventions to Reduce Internalized Stigma in individuals with Mental Illness: A Systematic Review. Span J Psychol. 2019;22:E27.
  • 10. Tsang HW, Ching SC, Tang KH, et al. Therapeutic intervention for internalized stigma of severe mental illness: A systematic review and meta-analysis. Schizophr Res. 2016;173:45-53.
  • 11. Brohan E, Gauci D, Sartorius N, Thornicroft G, Group GA-ES. Self-stigma, empowerment and perceived discrimination among people with bipolar disorder or depression in 13 European countries: the GAMIAN-Europe study. J Affect Disord. 2011;129:56-63.
  • 12. Latalova K, Ociskova M, Prasko J, et al. Self-stigmatization in patients with bipolar disorder. Neuro Endocrinol Lett. 2013;34:265-72.
  • 13. Sarisoy G, Kacar OF, Pazvantoglu O, et al. Internalized stigma and intimate relations in bipolar and schizophrenic patients: a comparative study. Compr Psychiatry. 2013;54:665-72.
  • 14. Ustundag MF, Kesebir S. [Internalized stigmatization in bipolar patients: relationship with clinical properties, quality of life and treatment compliance]. Turk Psikiyatri Derg. 2013;24:231-9.
  • 15. Ibrahim AW, Mukhtar YM, Sadique PK, et al. A facility-based assessment of internalized stigma among patients with severe mental illnesses in Maiduguri, North-Eastern Nigeria. 2016;6:1-11.
  • 16. James TT, Kutty VR. Assessment of internalized stigma among patients with mental disorders in Thiruvananthapuram district, Kerala, India. Asia Pac J Public Health. 2015;27:439-49.
  • 17. Ritsher JB, Otilingam PG, Grajales M. Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Res. 2003;121:31-49.
  • 18. Sadighi G, Khodaei MR, Fadaie F, Mirabzadeh A, Sadighi A. Self stigma among people with bipolar-I disorder in Iran. Iranian Rehabilitation Journal. 2015;13:28-32.
  • 19. West ML, Yanos PT, Smith SM, Roe D, Lysaker PH. Prevalence of Internalized Stigma among Persons with Severe Mental Illness. Stigma Res Action. 2011;1:3-10.
  • 20. Grande I, Berk M, Birmaher B, Vieta E. Bipolar disorder. Lancet. 2016;387:1561-72.
  • 21. Akers N, Lobban F, Hilton C, Panagaki K, Jones SH. Measuring social and occupational functioning of people with bipolar disorder: A systematic review. Clin Psychol Rev. 2019;74:101782.
  • 22. Chen M, Fitzgerald HM, Madera JJ, Tohen M. Functional outcome assessment in bipolar disorder: A systematic literature review. Bipolar Disord. 2019;21:194-214.
  • 23. Wang J, Mann F, Lloyd-Evans B, Ma R, Johnson S. Associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review. BMC Psychiatry. 2018;18:156.
  • 24. Au CH, Wong CS, Law CW, Wong MC, Chung KF. Self-stigma, stigma coping and functioning in remitted bipolar disorder. Gen Hosp Psychiatry. 2019;57:7-12.
  • 25. Greenberg S, Rosenblum KL, McInnis MG, Muzik M. The role of social relationships in bipolar disorder: a review. Psychiatry Res. 2014;219:248-54.
  • 26. Hawke LD, Parikh SV, Michalak EE. Stigma and bipolar disorder: a review of the literature. J Affect Disord. 2013;150:181-91.
  • 27. Levy 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.
  • 28. Rusch N, Todd AR, Bodenhausen GV, Olschewski M, Corrigan PW. Automatically activated shame reactions and perceived legitimacy of discrimination: A longitudinal study among people with mental illness. J Behav Ther Exp Psychiatry. 2010;41:60-3.
  • 29. Nilsson KK, Jorgensen CR, Craig TK, Straarup KN, Licht RW. Self-esteem in remitted bipolar disorder patients: a meta-analysis. Bipolar Disord. 2010;12:585-92.
  • 30. Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry. 1978;133:429-35.
  • 31. Karadag F, Oral T, Yalcin FA, Erten E. [Reliability and validity of Turkish translation of Young Mania Rating Scale]. Turk Psikiyatri Derg. 2002;13:107-14.
  • 32. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62.
  • 33. Akdemir A, Turkcapar MH, Orsel SD, et al. Reliability and validity of the Turkish version of the Hamilton Depression Rating Scale. Compr Psychiatry. 2001;42:161-5.
  • 34. Ersoy MA, Varan A. Ruhsal hastalıklarda içselleştirilmiş damgalanma ölçeği Türkçe formu’nun güvenilirlik ve geçerlik çalışması. Türk Psikiyatri Dergisi. 2007;18:163-71.
  • 35. Rosenberg M. Rosenberg self-esteem scale (RSE). Acceptance commitment therapy Measures package. 1965;61:18.
  • 36. Çuhadaroğlu F. Adolesanlarda benlik saygısı [Uzmanlık Tezi] Hacettepe Üniversitesi Tıp Fakültesi. Ankara; 1986.
  • 37. Zimet GD, Dahlem NW, Zimet SG, Farley G. The multidimensional scale of perceived social support. Journal of personality assessment. 1988;52:30-41.
  • 38. Eker D, Arkar H. Factorial structure, validity, and reliability of revised form of the multidimensional scale of perceived social support. Türk Psikiyatri Dergisi. 2001;12:17-25.
  • 39. Zhi-guo W, Cheng-mei Y, Zhen W. Self-stigma in patients with mood disorders and its related factors. Journal of Shanghai Jiaotong University. 2011;31:1527.
  • 40. Lau YW, Picco L, Pang S, et al. Stigma resistance and its association with internalised stigma and psychosocial outcomes among psychiatric outpatients. Psychiatry Res. 2017;257:72-8.
  • 41. Shumet S, B WM, Angaw D, Ergete T, Alemnew N. Magnitude of internalised stigma and associated factors among people with bipolar disorder at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia: a cross-sectional study. BMJ Open. 2021;11:e044824.
  • 42. Olcay Ç, ÇUHADAR D. Bipolar bozukluğu olan hastalarda işlevsellik düzeyi ve içselleştirilmiş damgalama arasındaki ilişkinin belirlenmesi. Gümüşhane Üniversitesi Sağlık Bilimleri Dergisi. 2013;2:230-46.
  • 43. Perich T, Mitchell PB, Vilus B. Stigma in bipolar disorder: A current review of the literature. Aust N Z J Psychiatry. 2022:48674221080708. [published online ahead of print, 2022 Feb 16]. doi:10.1177/00048674221080708
  • 44. Scott J, Pope M. Cognitive styles in individuals with bipolar disorders. Psychol Med. 2003;33:1081-8.
  • 45. Baysal GÖD. Damgalanma ve ruh sağlığı. Arşiv Kaynak Tarama Dergisi. 2013;22:239-51.
  • 46. Aldinger F, Schulze TG. Environmental factors, life events, and trauma in the course of bipolar disorder. Psychiatry Clin Neurosci. 2017;71:6-17.
  • 47. Dunne L, Perich T, Meade T. The relationship between social support and personal recovery in bipolar disorder. Psychiatr Rehabil J. 2019;42:100-3.
  • 48. Johnson SL, Winett CA, Meyer B, Greenhouse WJ, Miller I. Social support and the course of bipolar disorder. J Abnorm Psychol. 1999;108:558-66.
  • 49. Johnson L, Lundstrom O, Aberg-Wistedt A, Mathe AA. Social support in bipolar disorder: its relevance to remission and relapse. Bipolar Disord. 2003;5:129-37.

Bipolar Bozuklukta İçselleştirilmiş Damgalama, Algılanan Sosyal Destek ve Öz Yeterlilik Arasındaki İlişki

Yıl 2022, Cilt: 32 Sayı: 3, 350 - 357, 01.08.2022
https://doi.org/10.54005/geneltip.1104022

Öz

Amaç: Akıl hastalığı olan birçok insan, sosyal ve nesnel dışlanmaya, ayrımcılığa ve damgalanmaya maruz kalmaktadır. Damgalanmaya en çok maruz kalan ruhsal hastalıklardan biri bipolar bozukluktur (BB). Bu çalışmanın amacı, BB hastalarının içselleştirilmiş damgalamalarını belirlemek ve algılanan sosyal destek, benlik saygısı ve klinik değişkenler arasındaki ilişkiyi ortaya koymaktır.
Gereç ve yöntem: Bu kesitsel çalışma BB tanılı 103 hasta ile yürütülmüştür. Bu çalışmada veri toplamak için sosyodemografik form, Ruhsal Hastalıkların İçselleştirilmiş Damgalanması Envanteri (ISMI), Rosenberg Benlik Saygısı Ölçeği (RSE), Çok Boyutlu Algılanan Sosyal Destek Ölçeği (MSPSS) kullanılmıştır.
Bulgular: 103 hastanın yaş ortalaması 40.67±10.53 idi. Bu katılımcıların 46'sı (%44.7) kadındı. ISMI puanı, işsiz olanlarda bir işte çalışanlardan daha yüksekti (p=0.050). ISMI skorları açısından rezidüel semptomları olanlar, olmayanlara göre anlamlı olarak daha yüksek skorlara sahipti (p=0.001). İlaçlarını uyumsuzluğu olanların ISMI puanları, ilaçlarına uyumlu olanlara göre anlamlı olarak daha yüksekti (p=0.004). Depresyon sayısı (p<0.001; r=0.243) ve ilaç uyumsuzluğu (p<0.001; r=0.282) ile ISMI arasında pozitif korelasyon vardı. ISMI skoru ile RSE (r=-0.711; p<0.001) ve MSPSS (r=-0.384; p<0.001) arasında ise negatif korelasyon vardı. Çok değişkenli lineer regresyon analizinde düşük benlik saygısına sahip olanlar, arkadaşlarından daha düşük düzeyde sosyal destek bildirenler ve rezidüel semptomları olanlar arasında içselleştirilmiş damgalanma anlamlı olarak daha yüksekti.
Sonuç: Damgalama, benlik saygısı ve sosyal destek arasındaki bağlantı ve bunların BB hastaları üzerindeki etkileri psikiyatrik bakım için önemli çıkarımlara sahiptir. Bipolar bozuklukta damgalanmanın olumsuz etkilerini azaltmaya yönelik doğrudan müdahaleler, hastalık sonuçlarını iyileştirme potansiyeline sahip olabileceğinden klinik olarak göz önünde bulundurulmalıdır.

Kaynakça

  • 1. Huggett C, Birtel MD, Awenat YF, et al. A qualitative study: experiences of stigma by people with mental health problems. Psychol Psychother. 2018;91:380-97.
  • 2. Rusch N, Angermeyer MC, Corrigan PW. Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. Eur Psychiatry. 2005;20:529-39.
  • 3. Corrigan PW, Rao D. On the self-stigma of mental illness: stages, disclosure, and strategies for change. Can J Psychiatry. 2012;57:464-9.
  • 4. Rusch N, Corrigan PW, Todd AR, Bodenhausen GV. Implicit self-stigma in people with mental illness. J Nerv Ment Dis. 2010;198:150-3.
  • 5. Clement S, Schauman O, Graham T, et al. What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychol Med. 2015;45:11-27.
  • 6. Pal A, Sharan P, Chadda RK. Internalized stigma and its impact in Indian outpatients with bipolar disorder. Psychiatry Res. 2017;258:158-65.
  • 7. Post F, Pardeller S, Frajo-Apor B, et al. Quality of life in stabilized outpatients with bipolar I disorder: Associations with resilience, internalized stigma, and residual symptoms. J Affect Disord. 2018;238:399-404.
  • 8. Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: a systematic review and meta-analysis. Soc Sci Med. 2010;71:2150-61.
  • 9. Alonso M, Guillen AI, Munoz M. Interventions to Reduce Internalized Stigma in individuals with Mental Illness: A Systematic Review. Span J Psychol. 2019;22:E27.
  • 10. Tsang HW, Ching SC, Tang KH, et al. Therapeutic intervention for internalized stigma of severe mental illness: A systematic review and meta-analysis. Schizophr Res. 2016;173:45-53.
  • 11. Brohan E, Gauci D, Sartorius N, Thornicroft G, Group GA-ES. Self-stigma, empowerment and perceived discrimination among people with bipolar disorder or depression in 13 European countries: the GAMIAN-Europe study. J Affect Disord. 2011;129:56-63.
  • 12. Latalova K, Ociskova M, Prasko J, et al. Self-stigmatization in patients with bipolar disorder. Neuro Endocrinol Lett. 2013;34:265-72.
  • 13. Sarisoy G, Kacar OF, Pazvantoglu O, et al. Internalized stigma and intimate relations in bipolar and schizophrenic patients: a comparative study. Compr Psychiatry. 2013;54:665-72.
  • 14. Ustundag MF, Kesebir S. [Internalized stigmatization in bipolar patients: relationship with clinical properties, quality of life and treatment compliance]. Turk Psikiyatri Derg. 2013;24:231-9.
  • 15. Ibrahim AW, Mukhtar YM, Sadique PK, et al. A facility-based assessment of internalized stigma among patients with severe mental illnesses in Maiduguri, North-Eastern Nigeria. 2016;6:1-11.
  • 16. James TT, Kutty VR. Assessment of internalized stigma among patients with mental disorders in Thiruvananthapuram district, Kerala, India. Asia Pac J Public Health. 2015;27:439-49.
  • 17. Ritsher JB, Otilingam PG, Grajales M. Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Res. 2003;121:31-49.
  • 18. Sadighi G, Khodaei MR, Fadaie F, Mirabzadeh A, Sadighi A. Self stigma among people with bipolar-I disorder in Iran. Iranian Rehabilitation Journal. 2015;13:28-32.
  • 19. West ML, Yanos PT, Smith SM, Roe D, Lysaker PH. Prevalence of Internalized Stigma among Persons with Severe Mental Illness. Stigma Res Action. 2011;1:3-10.
  • 20. Grande I, Berk M, Birmaher B, Vieta E. Bipolar disorder. Lancet. 2016;387:1561-72.
  • 21. Akers N, Lobban F, Hilton C, Panagaki K, Jones SH. Measuring social and occupational functioning of people with bipolar disorder: A systematic review. Clin Psychol Rev. 2019;74:101782.
  • 22. Chen M, Fitzgerald HM, Madera JJ, Tohen M. Functional outcome assessment in bipolar disorder: A systematic literature review. Bipolar Disord. 2019;21:194-214.
  • 23. Wang J, Mann F, Lloyd-Evans B, Ma R, Johnson S. Associations between loneliness and perceived social support and outcomes of mental health problems: a systematic review. BMC Psychiatry. 2018;18:156.
  • 24. Au CH, Wong CS, Law CW, Wong MC, Chung KF. Self-stigma, stigma coping and functioning in remitted bipolar disorder. Gen Hosp Psychiatry. 2019;57:7-12.
  • 25. Greenberg S, Rosenblum KL, McInnis MG, Muzik M. The role of social relationships in bipolar disorder: a review. Psychiatry Res. 2014;219:248-54.
  • 26. Hawke LD, Parikh SV, Michalak EE. Stigma and bipolar disorder: a review of the literature. J Affect Disord. 2013;150:181-91.
  • 27. Levy 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.
  • 28. Rusch N, Todd AR, Bodenhausen GV, Olschewski M, Corrigan PW. Automatically activated shame reactions and perceived legitimacy of discrimination: A longitudinal study among people with mental illness. J Behav Ther Exp Psychiatry. 2010;41:60-3.
  • 29. Nilsson KK, Jorgensen CR, Craig TK, Straarup KN, Licht RW. Self-esteem in remitted bipolar disorder patients: a meta-analysis. Bipolar Disord. 2010;12:585-92.
  • 30. Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry. 1978;133:429-35.
  • 31. Karadag F, Oral T, Yalcin FA, Erten E. [Reliability and validity of Turkish translation of Young Mania Rating Scale]. Turk Psikiyatri Derg. 2002;13:107-14.
  • 32. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62.
  • 33. Akdemir A, Turkcapar MH, Orsel SD, et al. Reliability and validity of the Turkish version of the Hamilton Depression Rating Scale. Compr Psychiatry. 2001;42:161-5.
  • 34. Ersoy MA, Varan A. Ruhsal hastalıklarda içselleştirilmiş damgalanma ölçeği Türkçe formu’nun güvenilirlik ve geçerlik çalışması. Türk Psikiyatri Dergisi. 2007;18:163-71.
  • 35. Rosenberg M. Rosenberg self-esteem scale (RSE). Acceptance commitment therapy Measures package. 1965;61:18.
  • 36. Çuhadaroğlu F. Adolesanlarda benlik saygısı [Uzmanlık Tezi] Hacettepe Üniversitesi Tıp Fakültesi. Ankara; 1986.
  • 37. Zimet GD, Dahlem NW, Zimet SG, Farley G. The multidimensional scale of perceived social support. Journal of personality assessment. 1988;52:30-41.
  • 38. Eker D, Arkar H. Factorial structure, validity, and reliability of revised form of the multidimensional scale of perceived social support. Türk Psikiyatri Dergisi. 2001;12:17-25.
  • 39. Zhi-guo W, Cheng-mei Y, Zhen W. Self-stigma in patients with mood disorders and its related factors. Journal of Shanghai Jiaotong University. 2011;31:1527.
  • 40. Lau YW, Picco L, Pang S, et al. Stigma resistance and its association with internalised stigma and psychosocial outcomes among psychiatric outpatients. Psychiatry Res. 2017;257:72-8.
  • 41. Shumet S, B WM, Angaw D, Ergete T, Alemnew N. Magnitude of internalised stigma and associated factors among people with bipolar disorder at Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia: a cross-sectional study. BMJ Open. 2021;11:e044824.
  • 42. Olcay Ç, ÇUHADAR D. Bipolar bozukluğu olan hastalarda işlevsellik düzeyi ve içselleştirilmiş damgalama arasındaki ilişkinin belirlenmesi. Gümüşhane Üniversitesi Sağlık Bilimleri Dergisi. 2013;2:230-46.
  • 43. Perich T, Mitchell PB, Vilus B. Stigma in bipolar disorder: A current review of the literature. Aust N Z J Psychiatry. 2022:48674221080708. [published online ahead of print, 2022 Feb 16]. doi:10.1177/00048674221080708
  • 44. Scott J, Pope M. Cognitive styles in individuals with bipolar disorders. Psychol Med. 2003;33:1081-8.
  • 45. Baysal GÖD. Damgalanma ve ruh sağlığı. Arşiv Kaynak Tarama Dergisi. 2013;22:239-51.
  • 46. Aldinger F, Schulze TG. Environmental factors, life events, and trauma in the course of bipolar disorder. Psychiatry Clin Neurosci. 2017;71:6-17.
  • 47. Dunne L, Perich T, Meade T. The relationship between social support and personal recovery in bipolar disorder. Psychiatr Rehabil J. 2019;42:100-3.
  • 48. Johnson SL, Winett CA, Meyer B, Greenhouse WJ, Miller I. Social support and the course of bipolar disorder. J Abnorm Psychol. 1999;108:558-66.
  • 49. Johnson L, Lundstrom O, Aberg-Wistedt A, Mathe AA. Social support in bipolar disorder: its relevance to remission and relapse. Bipolar Disord. 2003;5:129-37.
Toplam 49 adet kaynakça vardır.

Ayrıntılar

Birincil Dil İngilizce
Konular Klinik Tıp Bilimleri
Bölüm Original Article
Yazarlar

Gülin Özdamar Ünal 0000-0002-6750-468X

Bektaş Önal 0000-0002-2364-9262

Gökçe İşcan 0000-0003-0848-5201

İnci Atay 0000-0002-5124-5556

Yayımlanma Tarihi 1 Ağustos 2022
Gönderilme Tarihi 17 Nisan 2022
Yayımlandığı Sayı Yıl 2022 Cilt: 32 Sayı: 3

Kaynak Göster

Vancouver Özdamar Ünal G, Önal B, İşcan G, Atay İ. The Relationship between Internalized Stigma, Perceived Social Support and Self-Efficacy in Bipolar Disorder. Genel Tıp Derg. 2022;32(3):350-7.