Estigmatización de lo psiquiátrico en estudiantes de medicina y otros

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http://isp.sagepub.com/International Journal of Social Psychiatry

http://isp.sagepub.com/content/58/5/455The online version of this article can be found at:

DOI: 10.1177/00207640114085422012 58: 455 originally published online 30 June 2011Int J Soc PsychiatryJasovic-Gasic and Nadja P. Maric

a Totic, Dragan Stojiljkovic, Zorana Pavlovic, Nenad Zaric, Boris Zarkovic, Ljubica Malic, Marina Mihaljevic, MirosStigmatization of 'psychiatric label' by medical and non-medical students

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International Journal of

Social Psychiatry

58(5) 455462

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DOI: 10.1177/0020764011408542

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Introduction

Stigmatization is a global phenomenon of social labelling,

stamping a person in order to discriminate, degrade or

classify them in a socially undesirable category of being

harmful and dangerous. Stigma in relation to people with

mental illness can be understood as a combination of

problems of knowledge (ignorance), attitudes (prejudice)and behaviour (discrimination) (Thornicroft, Brohan,

Kassam, & Lewis-Holmes, 2008). Stigmatization of psy-

chiatric patients, which is widely present over the world,

affects treatment and socialization of psychiatric patients

and could be considered as an environmental risk factor

for mental illnesses (van Zelst, 2009). It is this phenome-

non that is responsible for the fact that a great number of

people with psychiatric disorders do not even try to ask

for medical help.

The very process of stigmatization could be considered

from two points of view: personal feeling of being stigma-

tized, i.e. self-stigma (feelings like anger, depression,

fear, anxiety, guilt, embarrassment (Dinos, Stevens,

Serfaty, Weich, & King, 2004)), or imputing a label to

other person, i.e. public stigma (stereotypes, prejudicesand discrimination (Corrigan & Watson, 2002). The lit-

erature suggests that being stigmatized is associated with

Stigmatization of psychiatric label bymedical and non-medical students

Sanja Totic,1,2 Dragan Stojiljkovic,2 Zorana Pavlovic,1

Nenad Zaric,2 Boris Zarkovic,2 Ljubica Malic,2 Marina Mihaljevic,1

Miroslava Jaovic-Gaic1,2 and Nadja P. Maric1,2

Abstract

Backround: Stigmatization of psychiatric patients is present both in the general population and among healthcare pro-fessionals.

Aim: To determine the attitudes and behaviour of medical students towards a person who goes to a psychiatrist, beforeand after psychiatric rotation, and to compare those attitudes between medical and non-medical students.

Methods: The study included 525 medical students (second and sixth year of studies) and 154 students of law. The study

instrument was a three-part self-reported questionnaire (socio-demographic data, Rosenberg Self-Esteem Scale and avignette depicting a young, mentally healthy person). The experimental intervention consisted of ascribing a psychiatriclabel to only one set of vignettes. All the vignettes (with or without the psychiatric label) were followed by 14 statementsaddressing the acceptance of a person described by vignette, as judged by social distance (four-point Likert scale).Results: Higher tendency to stigmatize was found in medical students in the final year, after psychiatric rotation (ZU =3.12, p = .002), particularly in a closer relationship (ZU = 2.67, p = .007) between a student and a hypothetical personwho goes to a psychiatrist. The non-medical students had a similar tendency to stigmatize as medical students beforepsychiatric rotation (ZU = 0.03, p = .975). Neither gender, nor the size of students place of origin or average academicmark was associated with the tendency to stigmatize in our sample. However, students elf-esteem was lower in thosewith a tendency to stigmatize more in a distant relationship ( = 0.157, p = .005).

Conclusions: Psychiatric education can either reinforce stigmatization or reduce it. Therefore, detailed analyses ofeducational domains that reinforce stigma will be the starting point for anti-stigma action.

Keywords

stigma, medical students, medical education, discrimination, psychiatry

1Clinic of Psychiatry, Clinical Centre Serbia, Belgrade, Serbia2School of Medicine, University of Belgrade, Serbia

Corresponding author:

Nadja P. Maric, Assoc. Prof., psychiatrist, Clinic for Psychiatry CCS,

Belgrade, Serbia, Pasterova 2

Email: [email protected]

ISP58510.1177/0020764011408542Mariet al.International Journal of S ocial Psychiatry

Article

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456 International Journal of Social Psychiatry 58(5)

low self-esteem (Link, Struening, Neese-Todd, Asmussen,

& Phelan, 2001; Verhaeghe, Braceke, & Bruynooghe

2008), one important personality dimension that reflects a

persons overall evaluation or appraisal of his or her own

worth, but little is known about the self-esteem of stigma-

tizers. Interestingly, according to Crandall and Cohen

(1994), possible candidates for individual differences thatwould lead to a greater or lesser rejection of a stigmatized

one include low self-esteem, alienation, authoritarianism

and social-cultural ideology.

Although some literature suggests that public stigma is

lower among younger people and individuals with higher

educational levels (Angermeyer, Matschinger, & Corrigan,

2004; Arvaniti, Samakouri, Kalamara, Bochtsou, Bikos, &

Livaditis, 2009), strong negative emotional reactions

towards people with mental illness have been found in sec-

ondary schoolchildren from different world regions

(Ronzoni, Dogra, Omigbodun, Bella, & Atilola, 2009;

Rose, Thornicroft, Pinfold, & Kassam, 2007) and in medi-

cal doctors and medical students (Ogunsemi, Odusan, &

Olatawura 2008; Schulze, 2007). The level of stigmatiza-

tion by medical students is uneven regarding different

disorders, such as schizophrenia, depression, obsessive-

compulsive disorder (OCD) and self-harm (Fernando,

Deane, & McLeod, 2010; Law, Rostill-Brookes, &

Goodman, 2009; Simonds & Thorpe, 2003) but sometimes

it seems that future doctors stigmatize psychiatric label

itself. When Ogunsemi et al. (2008) evaluated the effect of

psychiatric label attached to an apparently normal person

on the attitude of final year medical students, it resulted in

students wanting to maintain a significant distance from the

person labelled mentally ill.However, negative attitudes may be modified by the

level of education and direct contact with mentally ill peo-

ple, as has been shown in two studies from our region that

focused on Belgrade adolescents (Pejovi-Milovancevi,

Leci-Tosevski, Tenjovi, Popovi-Deusi, & Dragani-

Gaji, 2009) and Greek students and professionals (Arvaniti

et al., 2009). Chung, Chen, and Liu (2001) found that

Chinese medical and dental students were more accepting

towards a person labelled as mentally ill when compared

with social science and engineering students.

The present study was carried out at the School of

Medicine and the School of Law, University of Belgrade,using a hypothetical vignette of an apparently healthy

young person and experimentally manipulating attributions

of psychiatric label. The aim of this study was (1) to

record the attitudes and behaviour of medical students

towards a person with a psychiatric label before and after

the psychiatric rotation, (b) to compare the attitudes and

behaviour between medical and non-medical students, and

(c) to investigate associations between the level of stigma-

tization and students characteristics (demography, aca-

demic achievement and self-esteem).

Based on the results of previous studies, we hypothesized

that participants who had more knowledge about mental ill-

ness would have more positive attitudes and behaviour.

Previous similar research has never been conducted in

former Yugoslavia and Serbia, and there is no data to show

stigmatization on the national level.

Methods

The study was conducted in accordance with the provisions

of The Helsinki Declaration and independent consent was

obtained from the School of Medicine (Department for

Physiology and Forensic Medicine) and the School of Law

(Department for Tax Law), University of Belgrade.

Research setting

At the School of Medicine, University Belgrade, under-

graduate education in psychiatry is based on the tradi-

tional curriculum over a 30-week course in the fourth

year (a single course on clinical education), where stu-

dents participate in centralized sessions for theoretical

education (30 hours) alternating with smaller group ses-

sions at clinical sites (60 hours). Students are introduced

to the mental status exam and psychiatric interviewing as

well as the diagnostic features, epidemiology, clinical

course, treatment and neurobiology of the core psychiat-

ric disorders. Clerkship assignments are available in

inpatient units and partial hospital programmes and stu-

dents mostly rotate. This means that student contact is

with different patients in terms of either diagnosis or

phase of the il lness course. All clinical psychiatric expe-rience is gained in the fourth year. Second year students

have no school-related contact with psychiatry, while all

sixth year students complete the rotation and pass the

exam in psychiatry.

In our previous studies of attitudes towards psychiatry

as a career choice, fifth year students had lower attitude

scores regarding psychiatry in comparison to their younger

colleagues, when averaged on their background and atti-

tudes towards other residencies: positive attitude was evi-

dent in 15% sophomores and 16% seniors, while 25% and

47%, respectively, stated they would never consider psy-

chiatry as a possible residency (Mari, Stojiljkovi, Mileki,Milanov, Stevanovic, & Jaovi-Gai, 2009; Mari,

Stojiljkovi, Mileki, Milanov, Bijelic, & Jaovi-Gai,

2011). This decrease of interest was due to an increase in

the number of students who showed a negative attitude

towards psychiatry. However, although our data showed a

decrease in affinity towards psychiatry during studies, the

level of interested students is still one of the highest reported

in recent literature.

In the past couple of years, about 4.4% of total medical

school graduates applied for a residency in psychiatry (data

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Totic et al. 457

for year 2006, Postgraduate Studies Department at School

of Medicine, University of Belgrade). Finally, the ratio of

psychiatrists in Serbia was about 10 per 100,000 population

during the last decade.

Psychiatric services in Serbia have been mostly hospital

centred. The Serbian National Committee for Mental

Health was established in 2003 and de-stigmatization ofpersons with psychiatric disorders became part of the

National Strategy for Development of Mental Helath Care

in 2007 (Pejovi-Milovancevi et al., 2009).

Law students do not learn specifically about psychiatry,

i.e. how to recognize mental symptoms or disorders. There

is no particular subject such as Insanity defence or similar,

although they do have some information on how to protect

the rights of persons with psychiatric disorders. The draft of

the Mental Health Law (as a part of the National Strategy

for Development of Mental Health Care) is still beyond its

official application.

Both schools comply with the conditions of the Bologna

Declaration, the process to create a unique European higher

education area by making academic degree and quality

assurance standards more comparable and compatible

throughout Europe.

Participants and procedures

The study included students from the University of

Belgrade who in 2008 entered the second and sixth year at

the School of Medicine and students who in 2009 entered

the fourth year at the School of Law. Testing was per-

formed by some of the authors (NZ, BZ, LM and MM who

were students at this time) within the first semester, duringthe regular teaching (classes) in the above-mentioned

departments with the permission of teaching staff. All the

students who attended the lectures during one week (sur-

vey period) were invited to participate. Participants were

not familiar with the fact that psychiatrists would super-

vise the questionnaire. The study was designed as a rand-

omized cluster experiment.

The study instrument was a three-part self-reported

questionnaire. The first part included socio-demographic

data (gender, date of birth, secondary school finished,

population of place of residence), as well as average mark

within studies. The second part was the Rosenberg Self-Esteem Scale (Rosenberg, 1979), with 10 statements eval-

uated on a four-point Likert scale. The third part of the

questionnaire was a vignette depicting a young, mentally

healthy, but shy person, as well as 14 statements (attitudes

and behaviour) addressing the acceptance of a person

described by a vignette as judged by social distance (social

stigmatization), to be evaluated on a four-point Likert

scale. A higher social distance score indicated a stronger

rejection of the given subject. The case description and

the questionnaire were modified versions of those used in

previous studies (Chung et al., 2001; Ogunsemi et al.,

2008). Two statements from the original questionnaire

(Ogunsemi et al., 2008) were omitted as considered

culturally unsuitable.

Vignette

The text in the vignette was as follows:

NN is mainly considered to be a cheerful and happy person.

Surrounded by close people, NN easily shows own feelings

and opinions, while in the group of people NN does not

know, NN turns to a tense person. NN is generally in good

terms with cousins, as well as with the majority of other

people. We could say that NN leads a normal life for his/her

own age and that NN balance well with social life (making

friends) and studying.

Statements

Using the four-point Likert scale (1 = agree completely,

2 = agree, 3 = disagree, 4 = disagree completely), the

students determined how much they were in agreement

with the statements referring to the person featured in

the vignette.

Experimental intervention in the present study was to

impute a psychiatric label to the featured person by the

statement NN goes to a psychiatrist at the end of the

vignette text. There were two versions of the questionnaire:

with and without the psychiatric label. Each group of stu-

dents (cluster) was given one version of the questionnaire

so that they would not see the difference between the

vignettes; the labelled vignette was distributed to 49.5% ofthe second year students and 47.7% of the final year stu-

dents from the School of Medicine and to 49.4% of the final

year students from the School of Law).

In our pilot study, we showed that the questionnaire

was applicable to the Serbian population, the response

rate was high and the internal consistency was good

(Munjiza, Stojiljkovi, Mileki, Latkovi, Jaovi-Gai,

& Mari, 2010; Stojiljkovi, Music, Munjiza, Jaovi-

Gai, Totic-Poznanovic, & Mari, 2009). Moreover, our

data analysis yielded a two-factor structure of stigmatiz-

ing statements: stigma imputed in a distant or close rela-

tionship. Imputing stigma in the distant relationshipmeans discrimination and underestimation of a person at

the level of social conscience of an individual (items 1, 2,

4, 5, 7, 9, see Table 1). Stigma in the close relationship

refers to the contact that requires a higher level of inti-

macy between the subject and the object of stigmatization

(items 3, 8, 1014, see Table 1). The item number 6

(It would be uncomfortable to me to talk about my pri-

vate problems to NN) performed poorly in terms of inter-

nal consistency with other items and was thus omitted

from subsequent analyses.



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Statistical analysis

The data were statistically processed using the software

package PASW Statistics 18 (SPSS Inc. Chicago, IL).

Continuous variables were described using the arithmeticmean (M) and standard deviation (SD) statistics. The Mann-

Whitneys rank sum test (U), Pearsons chi-square test of

independence (2) and Spearmans correlation of ranks

(rho, ) . The two-factor structure of stigmatizing statements

was confirmed using principal components analysis with

promax oblique factor rotation.

Results

Description of the samples

A total of 679 students correctly filled in questionnaires;525 students were from the School of Medicine (229 second

year and 296 sixth year), while 154 were from the School of

Law. The socio-demographic characteristics of the students

are shown in Tables 2 and 3.

Stigmatization of psychiatric labelThe second year medical students showed similar levels

of social distance to the labelled and unlabelled person

from the vignette (ZU = 0.53, p = .600). They imputed

statistically significantly less stigma in a distant relationship

(ZU = 2.46, p = .014) with the labelled person, and the

same level of stigmatization in close interactions (ZU= 1.25,

p = .210) with the unlabelled person.

The sixth year students of medicine showed a higher dis-

tance to the labelled than to unlabelled person from the

vignette (ZU= 3.12,p = .002). The levels of stigmatization

in the distant relationship were not significantly different

(ZU = 0.39,p = .695), but the level of stigmatization in acloser relationship with the labelled person was signifi-

cantly higher (ZU= 4.94,p < .001).

Table 1. Factor structure of stigmatizing statements

Stigmatization

In distant relationship In close relationship

I would feel unpleasant if I sat next to NN in city transport. I would find it unpleasant to rent NN a flat.

It would upset me to buy something from NN in a shop. It would be disturbing to have NN for my hairdresser.

It would disturb me to meet NN at a meeting(birthday party, celebration).

I would be uncomfortable to share an office with NN.

I would refuse to play cards with NN. I would oppose the marriage of my sister/brother to NN.

I would complain if NN became my neighbour. Friendship with NN would psychologically press me.

I would feel uncomfortable to work with NN in the samecompany.

Friendship with NN would cause physical fatigue in me.

Being friends with NN would negatively affect my mental health.

Table 2. Socio-demographic characteristics of the students by the school and the year of studies

School of MedicineSecond year(n= 229)

School of MedicineSixth year(n= 296)

School of LawFourth year(n= 154)

Total(N= 679)

n % n % n % n %

Gender

Male 74 32.6 92 31.1 54 35.1 220 32.5Female 153 67.4 204 68.9 100 64.9 457 67.5

Place of origin (number of inhabitants)

>100,000 90 40.4 125 42.2 77 50.0 292 43.4


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Totic et al. 459

The students of law imputed similar levels of stigma tothe labelled and unlabelled person from the vignette in

terms of the total stigma score (ZU = 0.03,p = .975), dis-

tant (ZU= 0.24,p = .808) and close (ZU= 0.16,p = .873)

relationship.

Stigmatization in medical students beforeand after psychiatric rotation

The sixth year medical students had a statistically signifi-

cantly higher tendency to stigmatize the labelled person in

comparison to the second year medical students (ZU =

2.04,p = .042). The difference was also statistically sig-

nificant for close relationship (ZU = 2.67,p = .007), but

not for distant relationship (ZU= 0.59,p = .554) with the

labelled person.

No statistically significant differences were found

between second and sixth year medical students in terms of

stigmatization of the unlabelled person, neither in total stig-

matization score (ZU= 1.54,p = .122), nor in distant (ZU=

1.72,p = .085) and close (ZU = 0.98,p = .326) relation

with NN.

Stigmatization in medical and non-medicalstudents

The second year students of medicine were not statistically

significantly different from the students of law in terms of

total stigmatization (ZU = 0.12,p = .902), or distant (ZU =

0.99,p = .324) and close (ZU= 0.76,p = .445) relationship

with the labelled person. Similarly, the attitudes of these two

groups did not differ towards the unlabelled person (total

stigma score:ZU= 0.46,p = .643, distant relationship:ZU=

1.06,p = .291, close relationship:ZU= 0.49,p = .633).

No statistically significant differences were found

between the sixth year medical students and law students in

terms of total stigmatization score towards the labelledperson (ZU = 1.21, p = .227) and the distant relations

domain of stigmatization (ZU= 0.56,p = .576). The sixth

year medical students reported a higher level of stigmatiza-

tion in close interactions with the labelled person when

compared to the students of law (ZU= 2.79,p = .005).

The attitudes of these two groups did not differ towards

the unlabelled person (total stigma score:ZU = 1.22,p =

.223, distant relationship:ZU = 0.64,p = .520, close rela-

tionship:ZU= 1.58,p = .113).

Socio-demographic characteristics of students

and stigmatizationThe vignettes with or without a label were almost equally

distributed in relation to the socio-demografic characteris-

tics of the sample (Table 3).

The data showed that male and female students had a

similar tendency to stigmatize the psychiatric label (ZU =

0.71,p = .479). The differences were not statistically sig-

nificant in close (ZU = 0.64,p = .520) or in distant (ZU =

1.15,p = .252) relationships.

The students coming from larger (> 100,000 inhabitants)

and smaller (< 100,000) towns had a similar tendency to

stigmatize the psychiatric label (ZU= 1.33,p = .183). The

differences were not statistically significant in distant(ZU = 1.54, p = .123) or close (ZU = 1.02, p = .306)

relationships.

Average academic mark and stigmatization

Average academic mark was not statistically significantly

correlated to stigmatization of the psychiatric label ( =

0.045,p = .430). Neither the distant ( = 0.039,p = .448)

nor close ( = 0.087,p = .126) domain of social interactions

with NN was correlated with an average academic mark.

Table 3. Socio-demographic characteristics of all students by vignette distribution

Non-labelled vignette(n = 345)

Labelled vignette(n = 334)

n % n %

Gender

Male 98 44.5 122 55.5Female 253 55.4 204 44.6

Place of origin (number of inhabitants)

>100,000 149 51.0 143 49.0


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Self-esteem and stigmatization

Self-esteem measured by the Rosenberg Self-Esteem Scale

(Rosenberg, 1979) was not statistically significantly corre-lated with the total score of stigmatization of the labelled

person ( = 0.019, p = .736). However, self-esteem was

negatively correlated with stigmatization in a distant rela-

tionship ( = 0.157, p = .005) and positively correlated

with stigmatization in a close relationship ( = 0.127,p = .023)

with NN.

Discussion

Medical education can both aggravate and reduce social dis-

tance towards a person who goes to a psychiatrist. The results

of our study show that medical students stigmatize a personwith a psychiatric label more in their final year, after psychi-

atric rotation. The non-medical students had a similar ten-

dency to stigmatize as the medical students before psychiatric

rotation. A higher level of stigmatization was evident in rela-

tions that require a closer relationship between the student

and the hypothetical person who sees a psychiatrist.

The data from this study are inconsistent with previously

published data. We did not confirm that medical students

stigmatize less that non-medical, as shown by Chung et al.

(2001), nor that final year students improve their attitudes

towards the mentally ill (Ay, Save, & Fidanoglu, 2006).

Neither gender, size of students place of origin nor

average academic mark was associated with the tendency

to stigmatize in our sample. However, a negative attitude

that resulted in maintaining a significant distance from the

labelled person was associated with students self-esteem:

students with lower self-esteem were more prone to input

stigma into distant relationship, while those whose self-

esteem was higher stigmatized in closer relationships.

From the literature, we know that self-esteem is an

important factor for the evaluation of self-stigma (Link

et al., 2001; Verhaeghe et al., 2008), but little is known

about the self-esteem of stigmatizers. Crandall and Cohen

(1994) evaluated personality of stigmatizer and concluded

that two factors predicted rejection: (1) a cynical world

view, characterized by alienation, loneliness and little faith

in people and (2) conventionalism, characterized by author-itarianism and a belief in a just world. However, the authors

did not find that self-esteem predicted the rejection. Our

findings show that lower self-esteem, associated with the

feeling of low competency and dependency on other peo-

ples approval, was associated with rejection in relations

that include the presence of others (meeting a labelled per-

son at a party or celebration, to work with him/her, etc.).

Our method used a vignette of an apparently normal per-

son labelled as goes to a psychiatrist, thus the results can

be interpreted not in relation to the particular disorder and

its treatment, but to psychiatry as a discipline. The findings

Figure 1. Stigmatizing statements in labelled and non-labelled vignette by the three groups of students



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Totic et al. 461

of the present study provide support for an earlier report by

our group on the attitudes of students towards psychiatry as

a career at the School of Medicine, Belgrade (Mari et al.,

2009; Mari et al., in press). In the sample of 105 sopho-

more and 75 senior students, we found a decrease in an

interest in psychiatry after students had completed the psy-

chiatric clerkship. The observed change was not due to adecrease in the number of interested students over the

course of medical education, but to an increase in the

number of students who show a negative attitude towards

psychiatry (typical answer: I would never choose psychia-

try for my future residency), view psychiatry unfavoura-

bly, and lack confidence and respect for both psychiatrists

and the field.

The precise origin of these unfavourable changes in stu-

dents attitudes towards psychiatry and a patient who sees a

psychiatrist is not known, but it is possible that contact with

patients with mental illness at the severe end of the spec-

trum may contribute, as suggested by Fernando et al.

(2010). Contact with a recovered patient could be effective

in reducing stigma (Thornicroft et al., 2008), but the exam-

ined students had classes that too frequently exposed them

to interactions with severe and hospitalized patients and the

training course was too short to observe the clinical course

that led to recovery. Also, if education overestimated the

factors of inheritance, but underestimated the nature and

nurture interactions, epigenetic dynamics and humanistic

approach that relies on individual potential more than limi-

tations due to symptoms, pessimistic attitudes towards the

effectiveness of treatment might be formed or sustained.

Even if appropriate educational intervention and expe-

rience are gained, the question arises about how long theireffects will sustain. In a one-year follow-up study in the

UK (Baxter, Singh, Standen, & Duggan, 2001), it was

shown that a positive change in medical students attitudes

towards psychiatry, psychiatrists and mental illness after

their fourth year psychiatric training was transient and

decayed over the final year. Medical students experience

significant distress from adjustment to the medical school

environment, perceived ethical and professional dilem-

mas, first-time exposure to death and human suffering,

personal life events and educational debt (Dyrbye, Thomas,

& Shanafelt, 2005). The data obtained by several authors

(Patenaude, Niyonsenga, & Fafard, 2003; Woloschuk,Harasym, & Temple, 2004) showed a decline in empathy

and an increase in cynicism during the course of medical

school. The decline in empathy could be related to aspects

of student distress and quality of life rather than progres-

sion through the training curriculum alone (Thomas et al.,

2007). Knowledge of to what degree stigma exists in

medical training is important as it leads to an understand-

ing of why psychiatry has low recruitment and how psy-

chiatric patients may be treated by doctors.

Stigma is inherent in the social structures that make up

society (Corrigan & Watson, 2002). The methods of

supplementary educational programmes in producing

enduring change in medical students attitudes towards psy-

chiatry, patients and mental illness should be associated

with interventions on a global, national level. In a way, our

research could be considered as a baseline assessment that

facilitates the evaluation of such global interventions at the

level of medical school.

Limitations

Finally, some limitations of the study should be mentioned.

Our method did not explore whether students had previous

personal (not school-related) experience with anyone who

goes to a psychiatrist. Although we are aware that a certain

experience can influence social distance in participants, we

intentionally avoided any question that could influence stu-

dents attitudes towards an unlabelled vignette. The gener-

alizability of the findings here cannot be assumed due to the

use of only two university schools, and further studies are

needed to analyse a randomly sampled Belgrade University

student population. However, only medical students have a

six-year undergraduate programme and other students can-

not be matched ideally. Another limitation is using an

unpaired sample of medical students; this problem could be

overcome by performing a longitudinal follow-up study.

We nevertheless believe that these restrictions do not reduce

the value and importance of our study.

Conclusion

Our study evaluated the tendency to stigmatize a hypotheti-

cal person who goes to a psychiatrist and showed that it washigher in the final year medical students in comparison to

younger colleagues and students of law. Since stigmatiza-

tion arises after a psychiatric rotation, this finding might be

associated with experiences gained through education and

could reflect attitudes and behaviour not only towards the

patient, but to psychiatry as a discipline.

Psychiatric education can either reinforce stigmatization

or reduce it. Therefore, detailed analyses of educational

domains that reinforce stigma are the starting point of any

anti-stigma action, in parallel with a national multisectoral

programme of action to promote the social inclusion of

people with mental illness.

References

Angermeyer, M. C., Matschinger, H. and Corrigan, P. W. (2004).

Familiarity with mental illness and social distance from people

with schizophrenia and major depression: Testing a model

using data from a representative population survey. Schizophrenia

Research 69: 175182.

Arvaniti, A., Samakouri, M., Kalamara, E., Bochtsou, V., Bikos, C.

and Livaditis, M. (2009). Health service staffs attitudes

towards patients with mental illness. Social Psychiatry and

Psychiatric Epidemiology 44: 658665.



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Estigmatización de lo psiquiátrico en estudiantes de medicina y otros

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