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

Background: Major Depressive Disorder (MDD) is a prevalent mental health condition often accompanied by selfstigma, negatively impacting self-esteem and empowerment. This study examines the mediating role of selfesteem 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.