How Stigma Shapes Mental Health: Pathways to Psychological Distress Among People Who Use Drugs

People who use drugs (PWUDs) experience high levels of psychological distress, often intensified by stigma. This study examined social pathways linking perceived stigma to psychological distress and assessed whether these relationships differed by history of non-fatal overdose. Using data from the Regional Health Cohort of 957 PWUDs in the US Midwest, we conducted path analysis in the full sample, followed by multigroup path analysis to assess whether these associations differed by overdose history. In the full sample, stigma, measured as perceived devaluation, was significantly associated with greater psychological distress, with approximately 18% of the total effect operating through reduced sense of belonging. Multigroup path analysis indicated structural differences across overdose history groups. Among individuals with a history of overdose, neither the direct nor indirect associations were statistically significant. These findings suggest that stigma is linked to psychological distress through reduced feelings of community inclusion. Public health interventions should focus not only on reducing structural stigma but also on strengthening social inclusion to improve mental health outcomes among marginalized populations.