Onic illnesses such as epilepsy[31], multiple sclerosis[32] and HIV/AIDS[33]. In fact, we found health-related stigma levels in young adults with narcolepsy approximating those found in people with HIV by Fife and Wright[21] using the SSIS. They Grazoprevir site reported stigma levels (mean(SD)) of social rejection = 19.9(6), financial insecurity = 8.1(3), internalized shame = 13.7(3) and social isolation = 17.8(4) in people with HIV. In comparison, in our controls the levels were 10.7(3), 4.1(2), 7.0(3) and 4.1(2) respectively. The finding of high levels of health-related stigma in young adults with narcolepsy is important as there is growing evidence that stigma contributes to economic disparities and difficulties with social relationships, and can affect access to and the quality of health care as well as adherence to a medication regimen[3]. The observed association of health-related stigma, particularly social rejection, with functioning found in our analyses support findings in other chronic illnesses[34?6] and suggests that interventions addressing the stigma process could promote better functioning in young adults with narcolepsy. Young adults with narcolepsy also reported lower health-related quality of life and greater anxiety and depression than young adults without narcolepsy. This is not surprising, and is in agreement with researchers who found that narcolepsy is associated with lower quality of life [7,11] and depression[37,38], especially in those with cataplexy[39]. Of concern is that the narcolepstics were particularly below the norm in role physical, vitality and social functioning, supporting findings previously reported by Daniels and colleagues[11]. Future research into and interventions to address these functional limitations in narcoleptics are indicated. We found that although on the whole, depression did not reach levels associated with clinical significance[40,41], it was directly related to lower functioning in both groups. However, 22 of the narcoleptics had depression scores greater than 10, suggesting clinically significant depression, while only 1 of the controls had depression scores greater than 10. Results from this study are consistent with studies of young adults with Type 1 diabetes [42,43], epilepsy[44,45], HIV[46] that identified stigma as part of living with the disease and emphasized the impact of stigma on emotional health, social relationships and self-management of the illness. Findings will advance the field of sleep medicine by identifying that the young adult with narcolepsy may feel stigmatized and this can be negatively affecting theirPLOS ONE | DOI:10.1371/journal.pone.0122478 April 21,9 /Stigma in Young Adults with Narcolepsydaily functioning and HRQOL. Now that this has been identified, many gaps remain. Research using qualitative methods may provide a richer understanding of health-related stigma from the perspective of the person with narcolepsy experiencing it. Future work is needed to characterize health-related stigma in middle age and older adults with narcolepsy. There is a need to develop and test strategies for prevention and management of stigmatization related to narcolepsy from the societal, organizational and individual perspective. Identifying people with narcolepsy at high risk for feeling stigmatized in order to implement preventive strategies is a SCH 530348 site promising area for future research. Studies of interventions for health-related stigma in HIV [47], mental illness[48,49] and epilepsy[50.Onic illnesses such as epilepsy[31], multiple sclerosis[32] and HIV/AIDS[33]. In fact, we found health-related stigma levels in young adults with narcolepsy approximating those found in people with HIV by Fife and Wright[21] using the SSIS. They reported stigma levels (mean(SD)) of social rejection = 19.9(6), financial insecurity = 8.1(3), internalized shame = 13.7(3) and social isolation = 17.8(4) in people with HIV. In comparison, in our controls the levels were 10.7(3), 4.1(2), 7.0(3) and 4.1(2) respectively. The finding of high levels of health-related stigma in young adults with narcolepsy is important as there is growing evidence that stigma contributes to economic disparities and difficulties with social relationships, and can affect access to and the quality of health care as well as adherence to a medication regimen[3]. The observed association of health-related stigma, particularly social rejection, with functioning found in our analyses support findings in other chronic illnesses[34?6] and suggests that interventions addressing the stigma process could promote better functioning in young adults with narcolepsy. Young adults with narcolepsy also reported lower health-related quality of life and greater anxiety and depression than young adults without narcolepsy. This is not surprising, and is in agreement with researchers who found that narcolepsy is associated with lower quality of life [7,11] and depression[37,38], especially in those with cataplexy[39]. Of concern is that the narcolepstics were particularly below the norm in role physical, vitality and social functioning, supporting findings previously reported by Daniels and colleagues[11]. Future research into and interventions to address these functional limitations in narcoleptics are indicated. We found that although on the whole, depression did not reach levels associated with clinical significance[40,41], it was directly related to lower functioning in both groups. However, 22 of the narcoleptics had depression scores greater than 10, suggesting clinically significant depression, while only 1 of the controls had depression scores greater than 10. Results from this study are consistent with studies of young adults with Type 1 diabetes [42,43], epilepsy[44,45], HIV[46] that identified stigma as part of living with the disease and emphasized the impact of stigma on emotional health, social relationships and self-management of the illness. Findings will advance the field of sleep medicine by identifying that the young adult with narcolepsy may feel stigmatized and this can be negatively affecting theirPLOS ONE | DOI:10.1371/journal.pone.0122478 April 21,9 /Stigma in Young Adults with Narcolepsydaily functioning and HRQOL. Now that this has been identified, many gaps remain. Research using qualitative methods may provide a richer understanding of health-related stigma from the perspective of the person with narcolepsy experiencing it. Future work is needed to characterize health-related stigma in middle age and older adults with narcolepsy. There is a need to develop and test strategies for prevention and management of stigmatization related to narcolepsy from the societal, organizational and individual perspective. Identifying people with narcolepsy at high risk for feeling stigmatized in order to implement preventive strategies is a promising area for future research. Studies of interventions for health-related stigma in HIV [47], mental illness[48,49] and epilepsy[50.
