A Mediation Analysis Evaluating Change in Self-Stigma on Diabetes Outcomes among People with Depression in Urban India: A Secondary Analysis from the INDEPENDENT Trial of the Collaborative Care Model

Self-stigma–the internalization of negative community attitudes and beliefs about a disease or condition–represents an important barrier to improving patient care outcomes for people living with common mental disorders and diabetes. Integrated behavioral healthcare interventions are recognized as evidence-based approaches to improve access to behavioral healthcare and for improving patient outcomes, including for those with comorbid diabetes, yet their impact on addressing self-stigma remains unclear. Using secondary data from the Integrating Depression and Diabetes Treatment (INDEPENDENT) study–a trial that aimed to improve diabetes outcomes for people with undertreated and comorbid depression in four urban Indian cities via the Collaborative Care Model–we longitudinally analyzed self-stigma scores and evaluated whether change in total self-stigma scores on diabetes outcomes is mediated by depressive symptom severity. Self-stigma scores did not differ longitudinally comparing Collaborative Care Model participants to enhanced standard-of-care participants (mean monthly rate of change in Self-Stigma Scale for Chronic Illness-4 Item scores; B = 0.0087; 95% CI: -0.0018, 0.019, P = .10). Decreases in total self-stigma scores over 12 months predicted diabetes outcomes at 12 months (HbA1c, total effect; B = 0.070 95%CI: 0.0032, 0.14; P < .05), however depressive symptoms did not mediate this relationship (average direct effect; B = 0.064; 95% CI: -0.0043, 0.13, P = .069). Considering the local and plural notions of stigma in India, further research is needed on culturally grounded approaches to measure and address stigma in India, and on the role of integrated care delivery models alongside multi-level stigma reduction interventions. Trial registration : ClinicalTrials.gov, NCT02022111. https://clinicaltrials.gov/study/NCT02022111.