Psychiatry · Medical Literature
Sex-specific predictors of self-stigma reduction in psychosis resulting from metacognitive interventions: Results from a randomized clinical trial.
Abstract
Research on gender differences in self-stigma among individuals with psychosis is limited. Gender differences have been found in factors associated with self-stigma, such as self-esteem, quality of life, and cognitive insight. This study aimed to determine predictors of self-stigma reduction in men and women after receiving Metacognitive Training (MCT) or a combined intervention delivering MCT alongside cognitive rehabilitation. Randomized clinical trial with two intervention branches. Participants were randomly allocated to one of two conditions: MCT or MCT alongside cognitive rehabilitation. Assessments were carried out before and after the intervention by blinded professionals. Linear mixed models, correlation analyses, and regressions were employed to examine the effect of treatment, relationships between variables, and potential predictors of treatment response in both groups for men and women, respectively. Self-stigma was reduced in both intervention groups, with no significant differences between them, suggesting both interventions were effective. Descriptive analyses revealed women reported higher self-stigma (n = 37, M = 63.78, SD = 14.01) than men (n = 40, M = 59.40, SD = 14.52). Regression analyses suggest that post-treatment self-stigma was predicted by different predictors according to sex. In women, self-esteem (R2 = 0.25, β = -2.31, p = 0.023) was a significant predictor of post-treatment self-stigma, while in men, quality of life significantly predicted self-stigma scores post-treatment (R2 = 0.37, β = -0.62, p < 0.001). Cognitive insight was not a significant predictor for either sex. Distinct pathways of self-stigma recovery emerged for women and men, underscoring the need for gender-sensitive interventions. These findings underscore the need for tailored stigma-reduction interventions that consider gender-specific factors influencing mental health outcomes. Longitudinal research should assess durability and further clarify gender-related mechanisms. https://clinicaltrials.gov/study/NCT06423651, Registration Number NCT06423651, 23/05/24.
Clinical relevance
Self-stigma in psychosis is a clinically significant barrier to recovery, yet sex-specific predictors of stigma reduction have been largely unexplored in intervention trials. This randomized clinical trial addresses that gap by examining whether men and women with psychosis respond to metacognitive interventions through distinct psychological pathways. Given that self-stigma adversely impacts treatment engagement, quality of life, and functional outcomes, identifying sex-stratified predictors is directly actionable for psychiatric treatment planning.
Key findings
1. Both Metacognitive Training (MCT) alone and MCT combined with cognitive rehabilitation significantly reduced self-stigma, with no statistically significant difference in efficacy between the two intervention arms, suggesting MCT is a robust core component regardless of augmentation. 2. At baseline, women (n = 37) reported higher mean self-stigma scores (M = 63.78, SD = 14.01) compared to men (n = 40; M = 59.40, SD = 14.52), indicating a sex difference in self-stigma burden at treatment entry. 3. In women, self-esteem was a significant predictor of post-treatment self-stigma (R² = 0.25, β = −2.31, p = 0.023), accounting for 25% of the variance in stigma outcomes, with higher self-esteem associated with lower post-treatment self-stigma. 4. In men, quality of life was a significant predictor of post-treatment self-stigma (R² = 0.37, β = −0.62, p < 0.001), accounting for 37% of the variance, with better quality of life associated with lower post-treatment self-stigma. 5. Cognitive insight was not a statistically significant predictor of post-treatment self-stigma in either sex, suggesting it does not independently drive stigma reduction in this population across both intervention conditions. 6. The divergent R² values (women: 0.25 vs. men: 0.37) suggest that the identified predictors explain a meaningfully larger proportion of stigma variance in men than in women, implying additional unmeasured sex-specific factors may influence women's stigma trajectories.
Practice implications
Clinicians delivering metacognitive interventions for psychosis should adopt sex-sensitive treatment targets: for women, adjunctive strategies that explicitly bolster self-esteem (e.g., self-compassion modules, strength-based cognitive techniques) may enhance self-stigma reduction, while for men, interventions addressing functional domains and subjective quality of life (e.g., social role engagement, vocational rehabilitation) should be prioritized alongside MCT. Patient selection and outcome monitoring should incorporate sex-stratified baseline assessments of self-esteem and quality of life as prognostic markers, rather than applying uniform treatment algorithms. Longitudinal follow-up studies are needed to determine whether these sex-specific gains in stigma reduction are durable and to identify additional mediators—particularly for women, in whom the current model explained less variance—to further refine gender-sensitive psychiatric care.