The Relationship Between Trait Mindfulness and Depression Severity Among People With Schizophrenia: The Role of Perceived Public Stigma Toward Mental Illness

Abstract

Background:

Studies have found that trait mindfulness is associated with lower levels of depressive symptoms among people diagnosed with schizophrenia. Still, the role of the perceived public stigma in this association has yet to be established.

Aims:

The purpose of this study was to assess the association between mindfulness and depressive symptoms experienced by people diagnosed with schizophrenia, controlling for the impact of their demographics and their perceived public stigma against mental illness.

Methods:

A quantitative descriptive correlational design was used. The sample included 184 Jordanian outpatients diagnosed with schizophrenia who completed self-administered measures of mindfulness, depressive symptoms, public stigma against mental illness, and demographic information. Multiple hierarchical regression analysis was performed to identify the unique variance in perceived depression explained by participants’ demographic and clinical variables, public stigma, and mindfulness.

Results:

Participants had moderate perceived discrimination and moderate to severe depression. Age, gender, perceived physical pain, perceived public stigma, and mindfulness were significantly correlated with depression among the study participants. After controlling for demographic and clinical variables, public stigma was significantly associated with depression and accounted for 14% additional variance above and beyond the 37% accounted for by demographic and clinical variables. Mindfulness accounted for a 15% additional variance above and beyond the variance accounted for by all other predictors.

Conclusion:

Anti-stigma programs could be combined with mindfulness-based interventions to reduce depression in people diagnosed with schizophrenia.

Keywords

stigma schizophrenia depression

Introduction

Schizophrenia is a chronic complex mental disorder that has many cognitive, behavioral, and emotional symptoms in the form of reality distortion, impaired mental capacity, communication difficulties, impaired affective response, poor relationships with others, and disruptive behaviors (Cuthbert & Morris, 2021). Depressive symptoms are prevalent in people with schizophrenia and can negatively affect their general health and response to treatments (Etchecopar-Etchart et al., 2021). Depressive symptoms in people with schizophrenia could also increase the risk for relapse, suicide, violence, substance abuse, poor quality of life, mental dysfunctioning, poor medication adherence, problems in family relationships, and a reduced chance of achieving functional remission (Conley et al., 2007; McGinty & Upthegrove, 2020; Yu et al., 2024). The prevalence of depression in people with schizophrenia was estimated to be 29% (Li et al., 2020). Socio-demographic and personal factors such as age, gender, duration of schizophrenia diagnosis, socioeconomic status, loneliness, and mental illness stigma are significant risk factors for depression in individuals with schizophrenia (Golubović et al., 2020; Rayan & Aldaieflih, 2019).

Public stigma is defined as discrediting and labeling a group of people due to stereotyped beliefs, negative attitudes, and discriminatory behaviors, resulting in feelings of disgust toward the group that is stigmatized and devalued (Link & Stuart, 2017). The behavioral expression of public stigma includes negative assessment of the stigmatized people and discrimination against them, such as a refusal to hire them, humiliating them, undermining their self-worth, and providing fewer resources for their treatment (Yanos, 2018). Public stigma against people with a chronic condition or mental illness exacerbates patients’ suffering, worsens their mental health, forces them to avoid treatment, and isolates them from the community (Gerlinger et al., 2013).

Stigma against mental illness is a global phenomenon, despite the presence of cultural differences in the sources of prejudice and beliefs about the causes of mental illness between people living in Eastern and Western countries (Krendl & Pescosolido, 2020; Rayan et al., 2018). Research indicates that schizophrenia is often viewed as the most stigmatized mental illness (Lee et al., 2016; Valery & Prouteau, 2022). In comparison with people diagnosed with mood disorders and anxiety disorders, people who have schizophrenia are the most stigmatized due to public discrimination, negative stereotyping like violence, and being least likely to recover (Jorm et al., 2012). Public stigma against people with schizophrenia affects various aspects of their daily lives, such as getting a job (Koschorke et al., 2014), social and romantic relationships (Koschorke et al., 2014), rehabilitation (Vass et al., 2017), social integration (Vass et al., 2017), and receiving treatment (Caqueo-Urízar et al., 2019). The social isolation and lack of familial respect caused by stigma can even lead to depression and suicide (Golubović et al., 2020).

There are some cultural misconceptions in Arab cultures about the origins of mental illness and how to cure it. These cultural beliefs and misconceptions have a significant impact on public attitudes toward patients with mental illnesses (Rayan & Fawaz, 2018; Rayan & Jaradat, 2016). Surprisingly, in the Jordanian context, some psychiatric nurses also hold unfavorable attitudes and cultural prejudices toward people with mental illness (Rayan, 2022).

Currently, antipsychotics are the standard approach in schizophrenia treatment. Despite improved outcomes, many people with schizophrenia may not fully recover, and many of them report stigma and depression, and the diagnosis of schizophrenia profoundly impacts their lives. Research shows that stigma and self-esteem correlate negatively (Karakaş et al., 2016). Depression and worsened mental symptoms in people with schizophrenia can also be attributed to mental illness stigma (Komatsu et al., 2021). Therefore, in order to lessen the perceived stigma or its impacts on people with schizophrenia, scientific and evidence-based interventions are desperately needed.

Trait mindfulness refers to the general tendency of an individual to maintain attention and non-judgmental awareness of their thoughts, perceptions, and emotions experienced in the present moment during daily life (Krägeloh, 2020). A mindful person observes their thoughts and feelings as they arise, allowing them to pass without clinging to them. Similarly, when a mindful individual with a mental illness encounters negative evaluations or emotional reactions related to their condition, they can acknowledge these reactions without judgment and then let them go. This non-judgmental acceptance of thoughts, perceptions, and emotions may enhance psychological well-being and improve the quality of life for patients with schizophrenia (Rayan, 2017).

Although trait mindfulness is often considered an innate ability, it can also be cultivated through regular mindfulness practice (Blignault et al., 2023). Over the years, mindfulness practice has gained popularity as a therapeutic approach because of its beneficial effects on individuals with schizophrenia and psychotic disorders (Jansen et al., 2020). This practice is implemented through various intervention protocols that are collectively known as mindfulness-based interventions (MBIs).

MBIs include two prominent protocols: Mindfulness-Based Stress Reduction (MBSR) (Kabat-Zinn, 1982) and Mindfulness-Based Cognitive Therapy (MBCT) (Segal et al., 2013). Both approaches utilize mindfulness practices to promote psychological well-being and have remarkable empirical support (Sabe et al., 2024). Numerous therapeutic protocols have originated from MBSR and MBCT, each with its own unique structure, content, and therapeutic goals. Nevertheless, all MBIs maintain a shared emphasis on meditation practices, which cultivate mindfulness as their core component. Researchers advocate for the incorporation of these mindfulness techniques into nursing care for individuals with schizophrenia, as they significantly improve patients’ sense of hope and facilitate their recovery (Astuti et al., 2020).

Although mindfulness has its roots in the Buddhist tradition, many studies in Arab countries have documented its role in practice to improve physical and mental well-being in various clinical and non-clinical samples (Al-Ghabeesh et al., 2019, 2022; Rayan & Ahmad, 2017). Many studies address the stigma of mental illness among people with schizophrenia. However, no study has been found to investigate the role of mindfulness in reducing the negative impacts of public stigma against mental illness on depressive symptoms among this population in particular. Thus, this study aims to assess the association between mindfulness and depressive symptoms among people diagnosed with schizophrenia, controlling for the impact of their demographics and their perceived stigma against mental illness. The results of this study could provide valuable data that helps develop MBIs for people diagnosed with schizophrenia to support them and reduce the negative impact of stigma on their well-being.

Methodology

Research Design

This study utilized a quantitative descriptive correlational design to analyze numerical data related to participants’ demographics and their experiences of depressive symptoms, mental illness stigma, and mindfulness. The descriptive approach aids in accurately interpreting the data. The correlational aspect examines the linear relationships between the study variables. While it is important to note that correlation does not imply causation (Curtis et al., 2016), the correlational design is statistically strengthened by controlling for demographics and other main variables (e.g., perceived public stigma). This approach highlights the unique contributions of each variable associated with depression, providing clearer insights into the potential effectiveness of mindfulness as an intervention to reduce depression.

Sample

A sample of 184 Jordanian outpatients diagnosed with schizophrenia participated in the study. A convenience sampling technique was used to recruit participants from Amman, Jordan’s largest psychiatric outpatient clinic. Inclusion criteria were: (1) age over 18, (2) ability to read and write Arabic sufficiently to complete the study survey, (3) antipsychotics prescribed at a stable therapeutic dose, and (4) diagnosis of schizophrenia according to the DSM-V criteria. The exclusion criterion was having any coexisting physical, psychiatric, or neurologic disease requiring long-term treatment.

Measures

The Demographic Questionnaire

Participants filled out a questionnaire that collected demographic information, including gender, marital status, age, income, the duration of their schizophrenia diagnosis, and their perceived severity levels of physical pain. Pain severity was assessed using a numerical rating scale from 0 to 10, where 0 indicates no pain and 10 signifies the worst possible pain.

The Center for Epidemiological Studies Scale

The Center for Epidemiological Studies Scale (CES-D) measures the severity of depression symptoms (Radloff, 1977). It consists of 20 items, each rated on a Likert-type scale ranging from 0 to 3. It asks respondents to rate how often they experienced depression-related symptoms throughout the previous week. The overall score for the CES-D ranges from 0 to 60, with higher values suggesting more depressed symptoms. Four items (4, 8, 12, and 16) had scores reversed. A total score of 16 or higher suggests a risk of clinical depression. The CES-D exhibits high internal consistency, sensitivity, and specificity (Al-Modallal, 2010; Rayan, 2017).

Devaluation-Discrimination Scale

The 12-item Devaluation-Discrimination Scale (DDS) measures the extent to which people in a given society believe that a patient with a mental illness is as trustworthy and intelligent as the average person, thereby assessing the perceived public stigma associated with mental illness (Link et al., 1991). It is scored on a 6-point Likert-type scale from 1 to 6, and the possible total scores are 12–72. Elevated DDS scores are indicative of high public stigma surrounding mental illness. Link (1987) states that the DDS has good construct validity and satisfactory reliability across various populations.

Mindful Attention Awareness Scale

The Mindful Attention Awareness Scale (MAAS) is a self-report questionnaire that assesses awareness and attention in the present moment (Brown & Ryan, 2003). The scale comprises 15 items and has a single-factor score. Example items include: “I find it difficult to stay focused on what’s happening in the present,” “I could be experiencing some emotion and not be conscious of it until some time later,” “I forget a person’s name almost as soon as I’ve been told it for the first time,” “I find myself preoccupied with the future or the past,” “I do jobs or tasks automatically, without being aware of what I’m doing,” and “I tend to walk quickly to get where I’m going without paying attention to what I experience along the way.” The MAAS scale has excellent psychometric properties and has been validated across various populations globally. The 15-item Arabic version of the MAAS has a single-factor structure, Cronbach’s alpha = 0.95, and good concurrent validity (Rayan & Ahmad, 2017; Abu-Horirrah et al., 2022).

Data Collection and Ethical Considerations

The IRB approval was obtained from the IRB Committee at Zarqa University, as well as from the settings where data collection took place. Before data collection, all participants signed a consent form. Furthermore, respondents were informed that their participation in the research study was optional and that they had the choice to withdraw from the study without incurring any penalties or having a detrimental impact on the care they received. All participants received an explanation of the study’s purpose and procedure. Data confidentiality was ensured, and the completed questionnaires were kept in a closed office. One trained data collector was responsible for collecting data from all participants during their visit to the clinic.

Data Analysis

IBM SPSS software (version 25) was used to analyze the data. Descriptive statistics were used to present the study variables. To identify the participants’ depression correlates, independent t-test, one-way analysis of variance (ANOVA), and Pearson’s product–moment correlation were employed. Multiple hierarchical regression analysis was utilized to ascertain the contribution of mindfulness and public stigma to the severity of depression after controlling for participant demographics and clinical variables.

Results

Sample Characteristics

The study sample included 184 patients diagnosed with schizophrenia, aged 18–67 years (mean age = 30.69, SD = 11.32, 51.1% female) recruited from the largest psychiatric outpatient clinic in Amman. Sixty-six participants were married (35.9%). About 51.6% of the participants had a bachelor’s degree. The mean reported monthly family income was 536.49 JD (1 JD = 1.41 USD). About 64.7% of the participants were not employed. The mean duration of diagnosis was 9.13, ranging from 5 to 16 years. The mean pain score was 3.84, ranging from 0 to 8. The mean number of relapses was about 3, ranging from 2 to 14 (Table 1).

Table 1.

The Socio-Demographic Characteristics.

Variable	Category	Frequency	Percent
Gender	Female	94	51.1
Gender	Male	90	48.9
Education level	Primary	32	17.4
	Secondary	57	31.0
	Baccalaureate	95	51.6
Employment status	No	119	64.7
Employment status	Yes	65	35.3
Marital status	Married	66	35.9
	Unmarried	118	64.1
		M	SD
		3.69	11.32
Duration of diagnosis		9.13	3.72
Family monthly income		536.49	216.70
Level of pain		3.84	2.75
Frequency of relapse		3.08	3.78

Scores of Public Stigma Toward Mental Illness, Depression, and Mindfulness

Participants experienced moderate levels of perceived discrimination, with a mean DDS of 45.25 (SD = 4.80), ranging from 33 to 56. They also exhibited moderate to severe depression, indicated by a mean CES-D score of 35.8 (SD = 13.63), with scores ranging from 1 to 59. The mean score of MAAS was 2.90 (SD = 1.66), with a range from 1 to 6.

Factors Associated With Depression

The independent t-test results showed that female participants had significantly higher depression mean scores (M = 38.46) compared to their male counterparts (M = 35.27), p = .008. However, no significant difference in the mean scores of depression was found according to marital status and employment (p > .05), Table 2. Similarly, the results of one-way ANOVA showed no significant difference in the mean depression scores based on participants’ level of education (p > .05).

Table 2.

Differences in the Mean of Depression Based on the Demographic Variables.

Variable	Category	Mean	SD	t/F	p
Marital status	Married	37.36	11.80
Marital status	Unmarried	35.04	14.54	1.11	.269
Level of education	Primary	33.59	8.58	2.39	.95
	Secondary	39.07	13.21
	BCS	34.72	14.97
Employment	No	36.20	15.14	0.439	.661
Employment	Yes	35.27	10.41
Gender	Female	38.46	11.89	2.68	0.008
Gender	Male	33.16	14.83

Pearson’s product–moment correlation analyses examined the associations between depression and the continuous demographic and clinical variables. As shown in Table 3, depression scores were significantly and positively correlated with age (r = 0.184, p = .012), pain (r = 0.584, p < .001), and public stigma (r = 0.412, p < .001). A significant negative relationship was evident between mindfulness and depression scores (r = 0.626, p < .001).

Table 3.

Correlation Coefficients Between Depression and the Main Study Variables.

Statistic	Age	Income	Relapse frequency	Level of pain	Duration of illness	Mindfulness	Stigma
r	.184	−.114	.250	.584	−.138	−.626	.412
p	.012	.125	.080	<.001	.416	< .001	<.001

To examine the unique variance in perceived depression explained by participants’ demographic and clinical variables, public stigma, and mindfulness, multiple hierarchical regression analysis was performed. Table 4 presents the three models that estimate the unique prediction of these variables. The demographic and clinical variables, including age, gender, and pain severity, were entered into the first model. Together, these variables were significantly correlated with depression, F(3, 180) = 8, 89, p < .001. In this step, only pain had unique contributions to the model.

Table 4.

Hierarchical Multiple Regression of Gender, Age, Level of Pain, Stigma, and Mindfulness as Predictors of Depression.

	Variable	Unstandardized coefficients		Standardized coefficients		p	ΔR²
Model	Variable	B	SE b	Beta	t	p	ΔR²
1	(Constant)	21.168	5.527		3.830	.000	0.37
	Gender	−4.141	3.497	−.147	−1.184	.243
	Age	.077	.131	.070	.583	.563
	Pain Severity	2.696	.645	.523	4.178	.000
2	(Constant)	−24.353	13.936		−1.747	.087	0.14
	Gender	−6.396	3.202	−.227	−1.998	.052
	Age	.006	.120	.005	.049	.961
	Pain Severity	1.343	.696	.261	1.929	.060
	Stigma	1.170	.335	.455	3.495	.001
3	(Constant)	28.688	16.705		1.717	.093	0.15
	Gender	−7.691	2.705	−.273	−2.844	.007
	Age	−.329	.126	−.303	−2.623	.012
	Pain Severity	1.316	.585	.255	2.250	.030
	Stigma	.654	.304	.254	2.149	.037
	Mindfulness	−4.718	1.060	−.563	−4.450	.000

The second step examined whether public stigma was significantly correlated with depression after controlling for demographic and clinical variables. In this step, the overall model was found to be significant, F (4, 179) = 11.35, p < .001. Public stigma accounted for 14% additional variance above and beyond the 37% accounted for by demographic and clinical variables. In this step, only public stigma had a unique contribution to the model.

The last model examined the unique contribution of mindfulness in depression, controlling for demographic and clinical variables, pain, and public stigma. The overall model was found to be significant, F(5, 178) = 16.83, p > .001. In this model, all predictors had unique contributions to depression (p < .05). Mindfulness accounted for 15% additional variance above and beyond the variance accounted for by all other predictors (Table 4).

Discussion

To the best of our knowledge, this is the first study to examine the role of perceived public stigma toward mental illness in the relationship between trait mindfulness and depression severity among people with schizophrenia. Worldwide, studies have found that greater levels of trait mindfulness are associated with lower levels of depressive symptoms among schizophrenia patients (Rayan, 2017; Sabe et al., 2024). However, in Arab countries, public stigma against people who have mental illness is deeply rooted in cultural, social, and systemic factors (Fekih-Romdhane et al., 2023; Rayan, 2022; Rayan & Aldaieflih, 2019), and its role in reducing the effectiveness of mindfulness interventions in improving psychological well-being should be highlighted.

Our results suggest that female gender, older age, and high level of pain were associated with depressive symptoms in people diagnosed with schizophrenia. Previous research has shown that women with schizophrenia may suffer from more depressive symptoms compared to their male counterparts (Leger and Neill, 2016; Li et al., 2022). Although hormonal differences could play a role in this gender difference, societal roles and stigma and discrimination that women may face could also contribute to their depression. Women with schizophrenia are also more likely to suffer from comorbid conditions, such as anxiety disorders, which can exacerbate depression (Etchecopar-Etchart et al., 2021). Older age among individuals with schizophrenia is associated with accumulated stressors, reduced support systems, financial difficulties, and medical illness, potentially leading to increased vulnerability to depression (D’Antonio & Serper, 2012). Perceived pain is also a crucial factor that can negatively affect mental health. High levels of pain experienced by people with schizophrenia can lead to feelings of helplessness and frustration, which can exacerbate their depressive symptoms (Brooks et al., 2019).

In the current study, public stigma accounted for 14% of the variance in depression after controlling for participants’ demographics and clinical variables. This outcome possibly reflects the role of stigma associated with Arab socio-cultural factors in the experience of depression among people with schizophrenia. When people with schizophrenia are aware of society’s discrimination against mental illness, they can experience feelings of inappropriate guilt, shame, hopelessness, and low self-esteem, increasing the severity of their depressive symptoms (Wood et al., 2014). Thus, reducing public stigma against people diagnosed with schizophrenia is crucial for improving their psychological well-being. The Jordanian community has not yet accepted people with mental illnesses in general (Rayan, 2022; Rayan & Aldaieflih, 2019). In addition, many Arabs think that mental illness is incurable and related to evil spirits (Rayan & Fawaz, 2018). Therefore, anti-stigma programs that promote acknowledgment of people with schizophrenia can encourage them to seek professional help, ultimately reducing their depression.

The current study indicates that public stigma against mental illness serves as a significant barrier to the impact of mindfulness on depression in people with schizophrenia. Public stigma against mental illness can reinforce negative self-perceptions and make it harder to cultivate non-judgmental acceptance, self-compassion, and attention to the current moment, the key aspects of mindfulness. Stigma against mental illness could not only reduce the effectiveness of MBIs but also hinder people with schizophrenia from participating in MBIs. People with schizophrenia may be afraid of being judged or discriminated against, which makes them reluctant to engage in MBIs. Furthermore, due to its adverse impacts on self-esteem and motivation, stigma could make people less inclined to engage in mindfulness practice (Tang et al., 2021).

Recently, there has been a growing interest in adapting MBIs to fit Arab cultural contexts (Rayan & Ahmad, 2017). Research indicates that MBIs can improve mental health, mainly when they are culturally relevant. For example, adaptations of mindfulness programs for Arabic speakers have shown promise in enhancing understanding and acceptance of mindfulness concepts, integrating them with everyday activities (Berkovich-Ohana et al., 2020; Blignault et al., 2023; Rayan & Ahmad, 2017). Thus, integrating MBIs with tailored client-centered and culturally relevant anti-stigma programs could play a significant role in promoting mental health among Arab people diagnosed with schizophrenia.

Limitations

The current study has some limitations that must be considered when interpreting its findings. First, because the study’s design was cross-sectional, longitudinal evaluations of depression severity predictors in people diagnosed with schizophrenia should be part of future research. Second, a limitation is associated with using a convenience sample, which may limit the generalizability and introduce bias to the results. Finally, some variables related to depression, such as social adjustment, life satisfaction, and negative symptoms, were not considered in the current investigation. Despite these limitations, the findings suggest pathways for developing and implementing intervention programs for improving the psychological health of people diagnosed with schizophrenia.

Implications for Clinical Practice

The current study shows that depression severity among patients diagnosed with schizophrenia was independently correlated with variables that are amenable to psychological and medical interventions in health care settings (i.e., pain severity, perceived stigma toward mental illness, and mindfulness). Subsequently, psychiatric nurses should consider these variables when implementing supporting programs for people diagnosed with schizophrenia. Addressing stigma is crucial for maximizing the benefits of mindfulness for depression. Thus, combining anti-stigma programs with MBIs has the potential to reduce depression in people diagnosed with schizophrenia. Culturally tailored anti-stigma campaigns may also enhance the effectiveness of MBIs in this population in particular.

Conclusions

This study identified the unique role of demographic and clinical variables, mental illness stigma, and mindfulness in depression severity among people diagnosed with schizophrenia. The findings of the study suggest that depression severity among patients diagnosed with schizophrenia was independently correlated with pain severity, perceived stigma toward mental illness, and mindfulness. Thus, reducing pain and stigma and increasing mindfulness may help alleviate depressive symptoms in this population. The high prevalence of perceived stigma against mental illness in the Arab population could significantly impact the effectiveness of psychological interventions delivered to patients with mental illness. Addressing cultural misconceptions and public stigma against mental illness is essential for improving mental health outcomes in this population in particular.

Footnotes

Author Contributions

The article is the author’s original work. The study includes one author. The author contributed to all study aspects including conception, design, acquisition, analysis, interpretation, manuscript drafting, critically revision of the manuscript, and the final approval of the version that was submitted for publication. The author agrees to be accountable for all aspects of the work, ensuring integrity and accuracy.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Deanship of Research and Graduate Studies, Zarqa University, Jordan.

Ethics Approval

The IRB was obtained from the IRB committee at Zarqa University. Approvals were obtained to collect data from all settings. The research conforms to the provisions of the Declaration of Helsinki (as revised in Brazil 2013). All participants gave informed consent for the research, and their anonymity was preserved.

ORCID iD

Ahmad Rayan

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