Since the late 1950s, a number of studies have documented that, all over the world, people who have a mental illness have to cope not only with symptoms and disabilities but also with stigma and prejudice.1–5 This “second illness”6 greatly inhibits—and may persist even after—recovery from the first.7–10
Prejudice and negative attitudes toward persons with mental illness are present even among medical professionals.11–15 Not only can such attitudes influence the quality of care medical personnel provide16 but they may also make it more difficult for patients with mental illness to talk about their physical problems with doctors.7
The situation is particularly serious in cases of people diagnosed with “schizophrenia,” because of the extreme stigma associated specifically with this diagnosis.3 Schizophrenia is a psychotic syndrome that commonly manifests as auditory hallucinations, bizarre delusions, disorganized speech, jumbled thinking, negative symptoms (e.g., apathy and blunted emotion), and significant social and occupational dysfunction.17 Despite important differences, the basic consensus among researchers is that biological, social, and psychological factors all contribute to the etiology of schizophrenia.17 Further, the majority of the research shows that the most effective treatment of this disorder consists of a combination of pharmacotherapy and psychosocial interventions.17 A substantial proportion of people with schizophrenia achieve a complete recovery, and many more regain “good” social functioning18 (although some research shows a “poor” outcome in 27% of patients at their first episode19). Although research suggests that optimism about outcome is justified, many still view schizophrenia as an incurable illness and those who have it as dangerous and unpredictable. Attempts—either by presenting schizophrenia “as an illness like any other”3,20 or by adopting a biogenetic causal model for this “brain disease”—to reduce prejudice, fear, and the desire to keep persons with this disorder at a distance have had the opposite effect.3,4,21–23 A recent review showed that, overall, biogenetic causal theories and labeling mental health problems as an “illness like any other” are positively related both to the perception that people with mental illness are dangerous and unpredictable and to a desire for social distance from such people.3 Of 19 studies reviewed, 18 found that belief in a genetic or other biological cause was associated with more negative attitudes toward people with mental health problems.3
Studies of persons with mental illness and their families and physicians regarding their perceptions of stigma toward mental illness reveal that the medical needs of those with schizophrenia are sometimes not taken seriously in medical settings.7 For example, some researchers have reported that medical doctors tend both to associate a mentally ill patient's physical complaints with the mental illness, suspecting that they are imaginary, and to underestimate symptom severity.16 Patients with mental illness have stated that when they are in the hospital, personnel there treat them with disrespect, keep them apart from the other patients, make them wait longer for a consultation with a specialist, and transfer them to a psychiatric unit as soon as possible.16
Epidemiological surveys reveal that the prevalence of cardiovascular and metabolic diseases is higher in persons diagnosed with schizophrenia than in the general population24,25 due partly to antipsychotic medications25 and partly to an adverse lifestyle.22 In addition, death from cancer is 50% higher in persons with this disorder than in the general population.26 These findings highlight the importance of training physicians so that they do not harbor negative attitudes about mental illness which could jeopardize the quality of the health care they provide to patients with such disorders.
Researchers have begun to carry out studies on medical students' beliefs about schizophrenia.27–32 These students—future doctors—represent an important target population for interventions to end stigmatization. Medical students seem to share the public's prejudices of persons with schizophrenia. Findings show that between 71% and 85% of medical students believe people with schizophrenia are unpredictable, 26% to 78% believe persons with schizophrenia are dangerous, and 6% to 21% consider schizophrenia to be incurable.27,28,30–32 Research has also revealed that medical students believe that schizophrenia and bipolar disorder are significantly more biological in etiology than are other mental disorders.33 The same study also showed that those students who favored biogenetic explanations of schizophrenia over psychosocial ones attributed less responsibility to patients for their symptoms.33 In one study, providing students with information showing that the causes of schizophrenia are psychological reduced their belief in the stereotype that people with the disorder are dangerous; providing students with information showing that the causes of the disease are biogenetic reduced their tendency to blame patients for their symptoms.34 Finally, researchers report that the label of “mental illness” is associated with a greater desire in medical students for social distance from patients with mental health problems.35
Here, we report data from our study on medical students' views of schizophrenia. In particular, we tested whether medical students who labeled a vignette case as “schizophrenia” and whether students who attributed the disorder to genetic factors (1) were more skeptical about the possibility that patients could be well again, (2) were more likely to believe that patients with the described symptoms were dangerous and unpredictable, and (3) were more likely to believe that people with the described symptoms “were kept at a distance by others.”
We invited all students in their fifth or sixth year of medicine at the Second University of Naples (Italy) who attended lectures from April through June 2010 to participate in the study. In Italy, medicine is a six-year academic degree (which students begin after they complete high school and pass a selection exam). During the fifth year, students receive training in psychiatry, which consists of didactic lessons on the clinical characteristics of mental disorders, biopsychosocial treatments, and the organization of mental health care in Italy. The training also entails a tutorial clinical workshop and completion of laboratories at the clinical facilities at the department of psychiatry of the university hospital. Participation in this study was voluntary. We sought consent by providing each eligible participant with written information on the purposes and content of the survey. We ensured the confidentiality and privacy of the participants by using an anonymous questionnaire and by keeping the completed questionnaires in a securely locked location. Given that our study was observational, was not clinical, and did not involve patients, and given the academic rules of the Second University of Naples, no formal approval was required from the local research ethical board.
Participants first read a case vignette describing (but not diagnosing) a person who met the International Classification of Diseases (ICD)-10 criteria for schizophrenia, and then they completed the Opinions on Mental Illness Questionnaire (OQ).2 The questionnaire required respondents to think about “people with problems like those described in the case vignette” (Appendix 1).
The OQ is a self-report tool exploring respondents' beliefs about the causes of, treatments for, and psychosocial consequences of schizophrenia.2 Others have previously tested its psychometric properties and found them to be satisfactory (Cohen kappa coefficients range from 0.50 to 1 for 74% of the items, and Cronbach alpha coefficients for the subscales range from 0.42 to 0.72).2 Two multiple-choice items, two open questions, and seven questions rated on a three-point scale explore students' beliefs and opinions regarding the most important and the most frequent causes of, and the treatments and psychosocial consequences of, the condition described in the case vignette (Appendix 1). In this paper, we report items related to the respondents' beliefs about the causes of the condition, their views regarding the possibility of patients with the condition being well again, their opinions of the unpredictability and dangerousness of people with the condition, and finally their perceptions of the extent to which others distance themselves from persons with the condition (four items, Cronbach alpha = 0.80).
We collected each respondent's age, sex, and interest in pursuing postgraduate training in psychiatry via additional questionnaire items.
We examined the relationships of respondents' causal explanations with diagnostic labeling using the χ2 test. Through analysis of variance (ANOVA), we explored, in relation to the causal explanation and diagnostic label, respondents' beliefs about (1) the possibility that patients will be well again (hereafter, “recovery”), (2) the unpredictability of persons with the condition described, (3) the dangerousness of people with the condition, and (4) the extent to which others keep their distance from people with the condition (hereafter, “social distance”). We examined the simultaneous effects of causal explanations and diagnostic labeling on respondents' beliefs about each of these four variables through regression analyses. We included variables in the multivariate analyses only if they reached statistical significance (P < .05) in ANOVA. We performed statistical analyses using SPSS (version 15.0; Chicago, Illinois).
Of the 232 medical students whom we invited to participate, 38 declined, leaving a final sample of 194, or 84%. Of those 194 participants, 85 (44%) were in the sixth (final) year of their degree. The mean age of the sample was 25.3 years (±2.9), and 83 (43%) students were male. All participants had completed the psychiatry training described above, and 19 (10%) stated that they were interested in pursuing postgraduate training in psychiatry.
In response to the multiple-choice list, heredity, endorsed by 157 students (81%), was the most frequently cited cause, followed by stress (133 students [69%]), psychological trauma (87 students [45%]), and misuse of street drugs (86 students [44%]; Table 1). Similarly, the respondents who answered the relevant questions considered heredity to be the most important cause (83 students [53% of 157 responding]) and the most frequent cause (51 students [33% of 153]).
Most of the students (n = 159; 82%) labeled the case described in the vignette as “schizophrenia.” Of those answering the relevant questions, a minority (n = 86; 24%) believed that persons with the case vignette disorder could be well again, very few (n = 8; 4%) believed that persons with problems like those described in the case vignette were dangerous, and some (n = 46; 26%) believed that they were unpredictable (Table 2).
The relationships of diagnostic labeling to respondents' causal explanations and views on the likelihood of recovery, opinions regarding unpredictability and dangerousness, and perceptions of social distance
Students who identified schizophrenia in the case vignette were more likely than others to believe that heredity is a cause (145/159 [91%] versus 12/34 [35%]; χ2 = 57.7, df 1; P < .0001) and less likely than others to believe that bad company (4/159 [2%] versus 4/34 [12%]; χ2 = 6.03, df 1; P < .02) and family conflicts (49/159 [31%] versus 20/34 [59%]; χ2 = 9.6, df 1; P < .002) are the cause. Moreover, they more frequently than others considered heredity as both the most frequent (51/124 [41%] versus 0/29 [0%]; χ2 = 17.9, df 1; P < .0001) and the most important (77/128 [60%] versus 6/28 [21%]; χ2 = 13.8, df 1; P < .0001) cause of schizophrenia.
Students who identified schizophrenia in the case vignette, compared with those who did not, were more pessimistic about recovery (2.1 ± 0.5 versus 2.5 ± 0.5; F = 13.5, df 1.185; P < .0001) and perceived a higher level of social distance (2.5 ± 0.4 versus 2.2 ± 0.5; F = 13.9, df 1.188; P < .0001).
The relationships of causal explanations to respondents' views on the likelihood of recovery, opinions regarding dangerousness and unpredictability, and perceptions of social distance
Students who believed that heredity is a cause were more pessimistic about recovery, were more likely to perceive unpredictability, and perceived more social distance (Table 3). Respondents who endorsed either alcohol/drug misuse or physical illness in pregnancy/childhood as a cause also perceived more social distance. Conversely, respondents who considered family conflicts to be a causal factor were more firmly convinced that people with the described disorder could be well again.
Multiple regression analyses revealed that respondents' beliefs about recovery were more pessimistic among students who endorsed heredity as a cause (Beta = −0.21, P < .013; r2 = 0.11; F of the model = 7.7; df 3, 182; P < .0001). Students' perceptions of social distance from people with schizophrenia were higher among those who believed that the described condition could be caused by heredity factors (Beta = 0.18, P < .03) and physical illness in pregnancy/childhood (Beta = 0.14, P < .051; r2 = 0.15; F of the model = 6.3; df 5, 183; P < .0001).
In line with other findings that health professionals strongly adhere to a biogenetic causal model of schizophrenia,33,36,37 the medical students in our study most frequently endorsed heredity as the cause; however, the fact that 69% and 45% of students in our study endorsed, respectively, stress and psychological trauma as a cause suggests that they also view schizophrenia according to a vulnerability–stress model.38 The vulnerability–stress theory of schizophrenia is frequently presented within the framework of a medical paradigm which assumes that psychosocial stressors have a causal role only to the extent that they trigger the clinical expression of a genetic vulnerability without which no amount of stress or trauma could cause schizophrenia. This version of the theory ignores, however, the fact that the originators of the model38 stated clearly that the vulnerability involved can be acquired via early adverse life events.39 Given that 53% of the responding students endorsed heredity as the most important cause, many of them may subscribe to the distorted vulnerability–stress model rather than to the original model.
Whereas the percentages of students who endorsed stress and misuse of drugs as causes were in line with those among Italian psychiatrists,13 the percentage of students who endorsed traumas was significantly higher (45% versus 29%; χ2 = 6.7, df 1; P < .009). These data could be related to recent studies which stressed the association of childhood traumas with the onset of psychoses.39,40 On the other hand, the fact that a relatively low percentage of students endorsed family conflicts as a cause of schizophrenia might be due to the changed position of the role of the family in disease—from factor causing onset to resource during and for recovery.41
In line with other studies on medical students' beliefs about recovery (6% to 21% of medical students view schizophrenia as incurable),27,28,30–32 24% of respondents firmly believed that persons with schizophrenia would be well again, and a further 72% partially believed recovery is possible. These findings reflect the discrepancy between the common belief that schizophrenia is a chronic, debilitating illness2,3 and the evidence from longitudinal studies that approximately 20% of people with this mental problem have a complete recovery (i.e., a loss of psychotic symptoms and a return to the premorbid level of functioning) and that 40% experience a social recovery (i.e., economic independence, living alone, and low social disruption).18 However, we must note that the students' general pessimism about recovery may have reflected uncertainty as to whether the question was asking if patients would get well spontaneously or with treatments, and if “be well again” should have been interpreted from a clinical or a functional perspective. We will specifically explore the meaning that medical students attribute to “recovery” in further ad hoc studies.
In our study, 4% of students believed that persons with schizophrenia were dangerous, and 26% perceived them as unpredictable. The low percentage of respondents who viewed persons with schizophrenia as dangerous could be due to the fact that the case vignette referred to the ICD-10 criteria for schizophrenia and therefore did not describe aggressive behaviors. Another possibility is that participants may have felt motivated to give socially desirable responses to these items. This hypothesis is supported by the high percentage of respondents who partially agreed that “others” are scared by persons with schizophrenia and that “others” keep these patients at distance (69% and 60%, respectively).
Also, any analysis of these data should take into consideration, as outlined by Jorm and Griffiths,23 that perceptions of dangerousness are influenced by the interpretation of the word “schizophrenia” in a given culture, where it is often amplified and/or misused by the media. In Italy, the most frequent metaphoric meaning of “schizophrenia” in newspapers is “incoherence/unpredictability,” while the nonmetaphoric usage of this word appears in news stories about criminal acts committed by “dangerous schizophrenic[s].”42
Respondents who identified schizophrenia in the vignette most frequently endorsed heredity as the cause. Heredity was also significantly associated with students' pessimism about patients' possible recoveries, with students' views of people with the disorder as unpredictable, and with students' perceptions of others' desire for social distance from persons with the disorder. These findings are consistent with the many studies that show a relationship between biogenetic explanations of schizophrenia and negative attitudes.20,43,44 Several authors3,21 point out that attributing schizophrenia to genetic factors, which are immutable and incurable, may allow physicians to acquit a patient from responsibility for his or her own behaviors but can simultaneously lead to an increase in stigmatization because the patient may be seen as an unpredictable, dangerous, and chronically ill person. Conversely, when people view schizophrenia as an individual's reaction to problematic life events and circumstances (e.g., poverty, loss, or family conflicts), they may feel that recovery is possible through improving environmental factors.3
Our results of the analysis of the relationship between the misuse of drugs as a cause of schizophrenia and the perception of social distance from persons with the disorder confirm previous data that also show a greater social distance from people with drug addictions than from those with other mental disorders.5,28,30,31 This finding probably reflects the students' knowledge of epidemiological data that demonstrate that persons with a drug addiction are at an increased risk for aggressive behaviors.45
As hypothesized, the label “schizophrenia” was associated with pessimism about the possibility of recovery and with perceptions of social distance from people with the disorder. The “schizophrenia” diagnosis may also function in future doctors as a stereotype through which behavior is narrowly interpreted,46,47 thereby increasing negative attitudes toward people with mental disorder diagnoses.3 As van Os47 stated,
the term schizophrenia may be considered stigma-inducing by itself, because it confusingly and mystifyingly refers to a “disease” that is characterised by a “split mind,” a psychological state that the public cannot personally relate to.... Schizophrenia does not correspond to any generally known human experience and, therefore, it is likely to induce fear and exclusion.
The stigma associated with schizophrenia may have a significant impact on the information that future doctors, regardless of their specialization, provide to their patients.48 In particular, presenting schizophrenia as a severe mental illness from which there is little hope of recovery may lead to low expectations in patients. These, in turn, may erode patients' hopes to “be well again” and to achieve their life goals. Also, patients' low expectations may align with illness chronicity (i.e., persisting symptoms and poor social functioning).32 Therefore, it is crucial that medical doctors acquire evidence-based and balanced knowledge about recovery in schizophrenia.18
This is the first study of medical students' views of schizophrenia carried out in Italy, one of the countries with the most years of experience in community mental health care.49 The use of a simple, self-reporting questionnaire facilitates not only the replication of the survey in other academic or medical contexts but also the ability to compare the beliefs of different populations (of students or others, such as psychologists or nurses) across different settings.
The study has several limitations that should be taken into account in the interpretation of its findings. Although the sample was relatively large, the survey was restricted to students from just one medical school in Italy; thus, it may not be representative of all medical students. Further, the study participants were students at a medical school located in Southern Italy, a region where professional attitudes toward persons with schizophrenia have been found to be more negative than in other geographical areas.36 In particular, residents in Southern Italy were less optimistic about recovery for, and less likely to acknowledge the affective rights (e.g., getting married, having children) of, persons with schizophrenia than were residents in Central or Northern Italy.36 The lack of a control group of other mental disorders is a further limitation of this survey, because attitudes vary in relation to specific mental disorders.28–31,33 Moreover, the lack of information about the faculty members' attitudes toward people with mental illness does not allow us to evaluate whether the students' beliefs reflect those of the faculty. Furthermore, the facts that the research had a cross-sectional design and included students only from two recent classes leave us unable to examine whether medical students' attitudes change over the course of their training.29,36 Finally, as mentioned above, the wording “be well again” on the OQ was ambiguous. We will specifically address all of these issues in future studies.
The results of this study confirm previous findings that biogenetic causal explanations of schizophrenia and diagnostic labeling have negative effects on students' beliefs about recovery from the disorder, their views on the unpredictability of people with the disorder, and their perceptions of social distance from persons with this disorder.11 One potential solution for changing this situation is to include dedicated lessons about recovery from, and the stigma associated with, schizophrenia50,51 in the training of medical students. Our faculty of medicine, for example, in consequence of this survey, now holds seminars for students in their fifth and sixth years on the scientific evidence base underlying schizophrenia and on the common prejudices regarding people with schizophrenia. In particular, the seminars address topics such as clinical and social recovery from schizophrenia, the association of schizophrenia with social danger, and the effects of prejudice against mental illness on mental health policies and on the quality of life of people who have such disorders. A second solution is to encourage student contact with “experience-based experts” who have recovered from, or are successfully living with, the symptoms of schizophrenia. Personal interaction with people with successful outcomes may counteract students' prejudices.51,52 Still another solution is to involve medical students in participatory research that specifically addresses and aims to change the behaviors that health professionals unconsciously adopt which discriminate against patients who are mentally ill. Improving the cultural competence of medical students in the area of mental health problems is yet another solution.32,48 In particular, students should receive training both on how to effectively communicate with a patient who is mentally ill when his or her mental disorder interferes and on how to handle their own emotional reactions to such patients. Finally, another solution is sensitizing medical students to the difficulties that people who are mentally ill have experienced—or still experience—in social, work, and health contexts. In Italy, for example, videos and mental health professionals' testimonies on the history of deinstitutionalization and the reform of Italian psychiatric health care laws53 could be used as destigmatizing, hope-inducing tools for training future Italian doctors. We hope that these strategies—by increasing students' awareness of the toxic effects of stigma—result in the same quality of medical care for, the same understanding of, and the same respect for patients with schizophrenia as are afforded other citizens.
The authors would like to thank the professors of the Faculty of Medicine of the Second University of Naples who facilitated the conduct of this study: A. Capuano, D. Cozzolino, A. Crisci, A. Filippelli, G. Delrio, A. Perna, S. Perrotta, F. Rossi, D. Ronca, M. Russo, N. Sannolo, and A. Scotto di Tella. They would also like to acknowledge Professor I. Levav, in the Research Unit of the Mental Health Services of the Israeli Ministry of Health, for his valuable comments on the final draft of this paper; Dolores Celona and Lorella Guariniello for their contribution in the collection of the data; the 194 participating students for their active involvement in the survey; the reviewers for their accurate comments on the first submitted version of this report to Academic Medicine; and Ms. E. Karlin, staff editor of Academic Medicine, for her careful editing work on the final version of this manuscript.
Given the nature of the study and the academic rules of the Second University of Naples which do not require observational, nonclinical studies that do not involve patients to have ethical approval, no formal approval was required from the local research ethical board. However, the authors were mindful of the rights and privacy of participants. Participation in the study was voluntary. They sought consent by providing written information on the purposes and content of the survey, and they ensured the confidentiality and privacy of the participants by using an anonymous questionnaire and storing the data in a securely locked place.
A poster on the preliminary results of this study was presented at the 2010 Scientific Day of the Second University of Naples, Italy; July 6 to 9, 2010.
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