The impact of self-stigma on empowerment in major depressive disorder: The mediating role of self-esteem and the moderating effects of socioeconomic and cultural context in an international multi-site study

Antonio Lasalvia; Chiara Bonetto; Tine van Bortel; Doriana Cristofalo; Evelien Brouwers; Mariangela Lanfredi; Jaap van Weeghel; Chih-Cheng Chang; Kok-Yoon Chee; Judit Harangozó; Chantal van Audenhove; Bola Ola; Fàtima Jorge-Monteiro; Bawo James; Uta Ouali; Arūnas Germanavičius; Jibril Abdulmalik; Alp Ucok; Yewande Oshodi; Graham Thornicroft

doi:10.1016/j.jad.2025.119802

The impact of self-stigma on empowerment in major depressive disorder: The mediating role of self-esteem and the moderating effects of socioeconomic and cultural context in an international multi-site study

Antonio Lasalvia^*
, Chiara Bonetto
, Tine van Bortel
, Doriana Cristofalo
, Evelien Brouwers
, Mariangela Lanfredi
, Jaap van Weeghel
, Chih-Cheng Chang
, Kok-Yoon Chee
, Judit Harangozó
, Chantal van Audenhove
, Bola Ola
, Fàtima Jorge-Monteiro
, Bawo James
, Uta Ouali
, Arūnas Germanavičius
, Jibril Abdulmalik
, Alp Ucok^*
, Yewande Oshodi
, Graham Thornicroft

^*Corresponding author for this work

Research output: Contribution to journal › Article › Scientific › peer-review

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Abstract

Background
Major Depressive Disorder (MDD) is a prevalent mental health condition often accompanied by self-stigma, negatively impacting self-esteem and empowerment. This study examines the mediating role of self-esteem in the relationship between self-stigma and empowerment and explores the moderating influence of socioeconomic and cultural contexts in an international sample.

Methods
This cross-sectional study, part of the ASPEN/INDIGO-Depression project, included participants with a diagnosis of MDD from 34 countries. Self-stigma, self-esteem, and empowerment were assessed using, respectively, the Internalized Stigma of Mental Illness (ISMI) scale, the Boston University Empowerment Scale (BUES), and the Rosenberg Self-Esteem Scale (RSES). A mediation model examined self-esteem's role in the self-stigma–empowerment relationship, and a conditional mediation model examined the moderating effect of the Human Development Index (HDI). All effects were adjusted for socio-demographic and clinical covariates.

Results
A total of 1058 people participated. Mediation analysis confirmed that self-esteem significantly mediated the negative association between self-stigma and empowerment, suggesting that lower self-stigma leads to higher self-esteem, which in turn enhances empowerment. Moderation analysis revealed that the mediation effect varied across countries with different socioeconomic and cultural contexts. The indirect effect of self-stigma on self-esteem was stronger in countries with higher HDI, indicating that individuals in these settings experience greater vulnerability to the negative effects of self-stigma on self-esteem.

Conclusions
Self-esteem buffers the negative impact of self-stigma on empowerment in people with MDD. The strength of this effect varies by socioeconomic and cultural context, with stronger mediation in higher-HDI countries. These findings highlight the need for tailored interventions addressing self-stigma in specific contexts to enhance empowerment and recovery.

Original language	English
Article number	119802
Number of pages	11
Journal	Journal of Affective Disorders
Volume	390
Issue number	1
Early online date	28 Jun 2025
DOIs	https://doi.org/10.1016/j.jad.2025.119802
Publication status	Published - 1 Dec 2025

Keywords

depression
self-stigma
empowerment
self-esteem
moderated mediation
multisite study

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10.1016/j.jad.2025.119802

The impact of self-stigma on empowerment in major depressive disorderFinal published version, 1.28 MBLicence: Taverne

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Lasalvia, A., Bonetto, C., van Bortel, T., Cristofalo, D., Brouwers, E., Lanfredi, M., van Weeghel, J., Chang, C.-C., Chee, K.-Y., Harangozó, J., van Audenhove, C., Ola, B., Jorge-Monteiro, F., James, B., Ouali, U., Germanavičius, A., Abdulmalik, J., Ucok, A., Oshodi, Y., & Thornicroft, G. (2025). The impact of self-stigma on empowerment in major depressive disorder: The mediating role of self-esteem and the moderating effects of socioeconomic and cultural context in an international multi-site study. Journal of Affective Disorders, 390(1), Article 119802. https://doi.org/10.1016/j.jad.2025.119802

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abstract = "Background Major Depressive Disorder (MDD) is a prevalent mental health condition often accompanied by self-stigma, negatively impacting self-esteem and empowerment. This study examines the mediating role of self-esteem in the relationship between self-stigma and empowerment and explores the moderating influence of socioeconomic and cultural contexts in an international sample. Methods This cross-sectional study, part of the ASPEN/INDIGO-Depression project, included participants with a diagnosis of MDD from 34 countries. Self-stigma, self-esteem, and empowerment were assessed using, respectively, the Internalized Stigma of Mental Illness (ISMI) scale, the Boston University Empowerment Scale (BUES), and the Rosenberg Self-Esteem Scale (RSES). A mediation model examined self-esteem's role in the self-stigma{\textendash}empowerment relationship, and a conditional mediation model examined the moderating effect of the Human Development Index (HDI). All effects were adjusted for socio-demographic and clinical covariates. Results A total of 1058 people participated. Mediation analysis confirmed that self-esteem significantly mediated the negative association between self-stigma and empowerment, suggesting that lower self-stigma leads to higher self-esteem, which in turn enhances empowerment. Moderation analysis revealed that the mediation effect varied across countries with different socioeconomic and cultural contexts. The indirect effect of self-stigma on self-esteem was stronger in countries with higher HDI, indicating that individuals in these settings experience greater vulnerability to the negative effects of self-stigma on self-esteem. Conclusions Self-esteem buffers the negative impact of self-stigma on empowerment in people with MDD. The strength of this effect varies by socioeconomic and cultural context, with stronger mediation in higher-HDI countries. These findings highlight the need for tailored interventions addressing self-stigma in specific contexts to enhance empowerment and recovery.",

keywords = "depression, self-stigma, empowerment, self-esteem, moderated mediation, multisite study",

author = "Antonio Lasalvia and Chiara Bonetto and \{van Bortel\}, Tine and Doriana Cristofalo and Evelien Brouwers and Mariangela Lanfredi and \{van Weeghel\}, Jaap and Chih-Cheng Chang and Kok-Yoon Chee and Judit Harangoz{\'o} and \{van Audenhove\}, Chantal and Bola Ola and F{\`a}tima Jorge-Monteiro and Bawo James and Uta Ouali and Arūnas Germanavi{\v c}ius and Jibril Abdulmalik and Alp Ucok and Yewande Oshodi and Graham Thornicroft",

year = "2025",

month = dec,

day = "1",

doi = "10.1016/j.jad.2025.119802",

language = "English",

volume = "390",

journal = "Journal of Affective Disorders",

issn = "0165-0327",

publisher = "Elsevier B.V.",

number = "1",

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Lasalvia, A, Bonetto, C, van Bortel, T, Cristofalo, D, Brouwers, E, Lanfredi, M, van Weeghel, J, Chang, C-C, Chee, K-Y, Harangozó, J, van Audenhove, C, Ola, B, Jorge-Monteiro, F, James, B, Ouali, U, Germanavičius, A, Abdulmalik, J, Ucok, A, Oshodi, Y & Thornicroft, G 2025, 'The impact of self-stigma on empowerment in major depressive disorder: The mediating role of self-esteem and the moderating effects of socioeconomic and cultural context in an international multi-site study', Journal of Affective Disorders, vol. 390, no. 1, 119802. https://doi.org/10.1016/j.jad.2025.119802

The impact of self-stigma on empowerment in major depressive disorder: The mediating role of self-esteem and the moderating effects of socioeconomic and cultural context in an international multi-site study. / Lasalvia, Antonio; Bonetto, Chiara; van Bortel, Tine et al.
In: Journal of Affective Disorders, Vol. 390, No. 1, 119802, 01.12.2025.

Research output: Contribution to journal › Article › Scientific › peer-review

TY - JOUR

T1 - The impact of self-stigma on empowerment in major depressive disorder

T2 - The mediating role of self-esteem and the moderating effects of socioeconomic and cultural context in an international multi-site study

AU - Lasalvia, Antonio

AU - Bonetto, Chiara

AU - van Bortel, Tine

AU - Cristofalo, Doriana

AU - Brouwers, Evelien

AU - Lanfredi, Mariangela

AU - van Weeghel, Jaap

AU - Chang, Chih-Cheng

AU - Chee, Kok-Yoon

AU - Harangozó, Judit

AU - van Audenhove, Chantal

AU - Ola, Bola

AU - Jorge-Monteiro, Fàtima

AU - James, Bawo

AU - Ouali, Uta

AU - Germanavičius, Arūnas

AU - Abdulmalik, Jibril

AU - Ucok, Alp

AU - Oshodi, Yewande

AU - Thornicroft, Graham

PY - 2025/12/1

Y1 - 2025/12/1

N2 - Background Major Depressive Disorder (MDD) is a prevalent mental health condition often accompanied by self-stigma, negatively impacting self-esteem and empowerment. This study examines the mediating role of self-esteem in the relationship between self-stigma and empowerment and explores the moderating influence of socioeconomic and cultural contexts in an international sample. Methods This cross-sectional study, part of the ASPEN/INDIGO-Depression project, included participants with a diagnosis of MDD from 34 countries. Self-stigma, self-esteem, and empowerment were assessed using, respectively, the Internalized Stigma of Mental Illness (ISMI) scale, the Boston University Empowerment Scale (BUES), and the Rosenberg Self-Esteem Scale (RSES). A mediation model examined self-esteem's role in the self-stigma–empowerment relationship, and a conditional mediation model examined the moderating effect of the Human Development Index (HDI). All effects were adjusted for socio-demographic and clinical covariates. Results A total of 1058 people participated. Mediation analysis confirmed that self-esteem significantly mediated the negative association between self-stigma and empowerment, suggesting that lower self-stigma leads to higher self-esteem, which in turn enhances empowerment. Moderation analysis revealed that the mediation effect varied across countries with different socioeconomic and cultural contexts. The indirect effect of self-stigma on self-esteem was stronger in countries with higher HDI, indicating that individuals in these settings experience greater vulnerability to the negative effects of self-stigma on self-esteem. Conclusions Self-esteem buffers the negative impact of self-stigma on empowerment in people with MDD. The strength of this effect varies by socioeconomic and cultural context, with stronger mediation in higher-HDI countries. These findings highlight the need for tailored interventions addressing self-stigma in specific contexts to enhance empowerment and recovery.

AB - Background Major Depressive Disorder (MDD) is a prevalent mental health condition often accompanied by self-stigma, negatively impacting self-esteem and empowerment. This study examines the mediating role of self-esteem in the relationship between self-stigma and empowerment and explores the moderating influence of socioeconomic and cultural contexts in an international sample. Methods This cross-sectional study, part of the ASPEN/INDIGO-Depression project, included participants with a diagnosis of MDD from 34 countries. Self-stigma, self-esteem, and empowerment were assessed using, respectively, the Internalized Stigma of Mental Illness (ISMI) scale, the Boston University Empowerment Scale (BUES), and the Rosenberg Self-Esteem Scale (RSES). A mediation model examined self-esteem's role in the self-stigma–empowerment relationship, and a conditional mediation model examined the moderating effect of the Human Development Index (HDI). All effects were adjusted for socio-demographic and clinical covariates. Results A total of 1058 people participated. Mediation analysis confirmed that self-esteem significantly mediated the negative association between self-stigma and empowerment, suggesting that lower self-stigma leads to higher self-esteem, which in turn enhances empowerment. Moderation analysis revealed that the mediation effect varied across countries with different socioeconomic and cultural contexts. The indirect effect of self-stigma on self-esteem was stronger in countries with higher HDI, indicating that individuals in these settings experience greater vulnerability to the negative effects of self-stigma on self-esteem. Conclusions Self-esteem buffers the negative impact of self-stigma on empowerment in people with MDD. The strength of this effect varies by socioeconomic and cultural context, with stronger mediation in higher-HDI countries. These findings highlight the need for tailored interventions addressing self-stigma in specific contexts to enhance empowerment and recovery.

KW - depression

KW - self-stigma

KW - empowerment

KW - self-esteem

KW - moderated mediation

KW - multisite study

U2 - 10.1016/j.jad.2025.119802

DO - 10.1016/j.jad.2025.119802

M3 - Article

C2 - 40588102

SN - 0165-0327

VL - 390

JO - Journal of Affective Disorders

JF - Journal of Affective Disorders

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Lasalvia A, Bonetto C, van Bortel T, Cristofalo D, Brouwers E, Lanfredi M et al. The impact of self-stigma on empowerment in major depressive disorder: The mediating role of self-esteem and the moderating effects of socioeconomic and cultural context in an international multi-site study. Journal of Affective Disorders. 2025 Dec 1;390(1):119802. Epub 2025 Jun 28. doi: 10.1016/j.jad.2025.119802