As modern society becomes increasingly complex, individuals face rising levels of stress, which in turn increase the possibility of developing mental illness (Aggarwal et al., 2013; Palma-Gudiel, Córdova-Palomera, Leza, & Fañanás, 2015; St-Jean-Trudel, Guay, & Marchand, 2009). Unfortunately, individuals with mental illness face a number of negative stigmas, including the notion that they are irrational, irresponsible, or even violent. Thus, serious mental illness can have a negative influence on the social life of an individual. This may be true even if the individual does not frequently experience symptoms or has found an effective treatment strategy.
Due to negative stereotypes and stigmas, people with mental illness may be perceived to have similar characteristics and may not be viewed as unique individuals by the general population and even medical professionals (Rüsch, Evans-Lacko, & Thornicroft, 2012). Negative attitudes toward individuals with mental illness may decrease their desire or willingness to access treatment, which may increase the severity of their illness and subsequently further hinder their ability to engage in normal social interactions. Indeed, individuals with mental illness face many forms of discrimination and prejudice, with long lasting negative effects. The World Health Organization pointed out in 2001 that the biggest obstacle preventing individuals with psychological health challenges from recovering is the stigma associated with mental illness (Dharitri, Rao, & Kalyanasundaram, 2015; Snyder, 2015). Therefore, this stigma has been a focus of sociology, social psychology, and psychiatry, as well as many other research fields. In recent years, stigmas regarding mental illness have received increasing attention as societies have emphasized the importance of education regarding psychological health. However, most previous studies examined patients or their families (Björkman, Svensson, & Lundberg, 2007; Hasan & Musleh, 2017; Ran et al., 2018; Sirey et al., 2001; Sun et al., 2019) and few assessed stigmas in medical students (Luo, He, Mohamed, & Rosenheck, 2018). Therefore, the current study examined stigmas regarding mental illness and associated attitudes in medical students from Shandong, China. The results may offer a basis for adopting measures to prevent or reduce negative attitudes toward people with mental illness.
Participants were full-time college students in four different years (i.e., freshman, sophomore, junior, and senior) at three medical universities in Shandong, China. A stratified cluster sampling method was adopted, and a survey questionnaire was conducted. In total, 758 questionnaires were distributed, and all were returned. Among these questionnaires, 735 were eligible for inclusion in the dataset, making the effective completion rate 97%. The study was approved by the medical ethics committee of Binzhou Medical University. Written consent was obtained from all participants prior to administration of the survey.
Researchers included a psychology professor (L.K.) and two undergraduate students majoring in Applied Psychology, who were carefully trained before administration of the survey. Researchers were assigned specific groups of students and asked to administer the survey using identical instructions. Surveys were completed during class. The questionnaires were submitted anonymously and collected by researchers upon completion.
The survey instrument was the Perceived Devaluation and Discrimination Scale (PDD), developed by Link, Yang, Phelan, and Collins (2004). The PDD is a commonly used instrument for evaluating how the general public perceives people with mental illness (Brohan, Slade, Clement, & Thornicroft, 2010). The scale comprises 12 items divided into two subscales: (a) perceived devaluation and (b) discrimination. The devaluation subscale asks participants about statements such as that most people devalue individuals with mental illness by thinking of them as losers, as less intelligent than other people, or as persons whose suggestions cannot be taken seriously. The other subscale assesses perceived discrimination regarding international friendship, jobs, and romantic relationships (Link et al., 2004). The survey includes a 5-point Likert scale, where 1 = totally agree and 5 = totally disagree for each item. The overall questionnaire score ranges from 12 to 60 points, with higher scores indicating more negative attitudes toward individuals with mental illness. The PDD has been used by the Chinese National Health Planning Commission to evaluate attitudes in community mental health workers. The Chinese version of the PDD was used in the current survey, which has been shown to have good validity and reliability (Cronbach's alpha = 0.70) (Yin, Xu, Yang, & Tian, 2014).
Epidata 3.0 with a double entry system was used for data entry, and SPSS 17.0 was used for statistical data analysis. The discrimination and perceived devaluation subscale scores were analyzed as well as the total scores (mean, SD). A single sample t test was used to compare the two subscales and total average scores with scores of 3 (i.e., neither agree nor disagree) on each item, which reflects a neutral attitude. Independent sample t test and variance analyses were used to compare the differences between the two subscale scores and total scores according to demographic variables. p < 0.05 indicated statistically significant differences.
The survey included 735 participants: 355 men and 380 women. A total of 221 participants lived in cities, 173 lived in towns, and 301 lived in rural areas, and 370 had no siblings. A total of 529 participants were studying medical psychology and 99 were studying psychiatry. Of participants, 672 reported that they were not religious. All participants were between ages 17 and 25, with a mean age of 20.18 (SD = 1.56 years).
Perceived Devaluation and Discrimination Scale Scores
Overall Scores. Perceived devaluation subscale scores were lower than the midpoint score (i.e., 3) (t = 9.07, p < 0.001), whereas discrimination subscale scores were higher than the midpoint score (t = 10.25, p < 0.001).
Scores By Gender. PDD scores were significantly lower in women compared with men (p < 0.001); however, there was no statistically significant difference in subscale scores among men and women (p > 0.05) (Table 1).
Perceived Devaluation and Discrimination Scale Scores by Gender
Scores By Year. Analysis of variance showed that students from different school years obtained statistically similar scores on the devaluation subscale and total scores (p > 0.05) but significantly different scores on the discrimination subscale (p < 0.001). In a further comparison, in which the Least Significant Difference method was used, freshman and sophomore students had higher discrimination scores than junior and senior students. There were differences in the comparison of devaluation subscale, discrimination subscale, and total scores of students in different school years (Table 2).
Perceived Devaluation and Discrimination Scale Scores by School Year
Participants Who Studied Medical Psychology. Compared with students who studied other topics, those who studied medical psychology obtained significantly lower scores on the discrimination subscale (p < 0.01). No differences were found in total scores or scores on the perceived devaluation subscale (p > 0.05) (Table 3).
Perceived Devaluation and Discrimination Scale Scores in Participants Who Studied Medical Psychology
Participants Who Studied Psychiatry. Compared with students who studied other topics, those who studied psychiatry obtained significantly lower total scores and scores on the discrimination subscale (p < 0.01). However, these participants scored higher than other participants on the devaluation scale (p > 0.05) (Table 4).
Perceived Devaluation and Discrimination Scale Scores in Participants Who Studied Psychiatry
In the current study, Chinese medical students obtained total scores on the PDD that were higher than the hypothetical midpoint score (i.e., 3), indicating that medical students had negative perceptions of individuals with mental illness. However, the average score on the devaluation subscale was lower than the midpoint score, indicating that medical students had some sympathy and understanding regarding individuals with mental illness. Scores on particular items in the discrimination scale that were higher than the midpoint score indicated that participants had negative attitudes toward individuals with mental illness in terms of social communication, work, love, and marriage.
These data indicate that medical students were more likely to engage in discrimination rather than devaluation with respect to individuals with mental illness. Indeed, compared with devaluation, discrimination has been found to be a more widespread negative attitude toward individuals with mental illness (Chan et al., 2016). Although people may show sympathy and understanding toward individuals with mental illness, they exhibit different attitudes, such as distrust, rejection, and even hostility, when faced with interactions involving work, social communication, and marriage (Rüsch, Brohan, Gabbidon, Thornicroft, & Clement, 2014; Snyder, 2015; St Louis & Roberts, 2013).
The current data indicate that gender significantly modulated PDD scores, especially discrimination scores. In general, men obtained lower scores than women, indicating that men are more likely to trust and accept individuals with mental illness in situations related to social interactions, work, and marriage. Previous work has found that, compared with men, women are more likely to believe that individuals with mental illness are dangerous (Kulesza, Raguram, & Rao, 2014). However, gender was not an important factor affecting devaluation scores. The reason might be that both men and women showed tolerance and even sympathy toward individuals with mental illness.
The data also indicated that school year influenced attitudes toward individuals with mental illness. Junior and senior students obtained lower scores on the discrimination scale compared with underclassmen. However, junior and senior students showed relatively negative attitudes toward individuals with mental illness, such as discrimination and hostility. Increased access to theoretical information about psychological diseases may help decrease negative perceptions of individuals with mental illness (Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003; Papish et al., 2013). Thus, improved education about psychological conditions for students and the general public is necessary to improve attitudes toward individuals with mental illness.
The current study has some limitations. First, all participants involved in the study were full-time college students at three medical universities of Shandong, China; therefore, further studies are needed to confirm the generalizability of the results across a more diverse population. Another limitation of the current study is its cross-sectional design. A longitudinal study is needed to further examine the attitude of medical students toward individuals with mental illness.
Chinese medical students appear to have negative attitudes toward individuals with mental illness, especially regarding social interactions, work, and marriage. Efforts to reduce medical students' discriminatory attitudes toward people with mental illness may include education about mental illness. Therefore, further studies are needed to develop educational interventions and programs to increase understanding and reduce negative attitudes toward people with mental illness.
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Perceived Devaluation and Discrimination Scale Scoresa by Gender
|Male (n = 355)||13.95 (3.01)||21.79 (3.33)||35.74 (5.44)|
|Female (n = 380)||14.13 (2.92)||22.98 (3.75)||37.11 (5.81)|
Perceived Devaluation and Discrimination Scale Scoresa by School Year
|School Year||Mean (SD)|
|Freshman (n = 203)||14.02 (3.21)||22.94 (3.93)||39.96 (6.29)|
|Sophomore (n = 203)||13.89 (3.01)||22.74 (3.60)||36.63 (5.79)|
|Junior (n = 230)||14.35 (2.74)||21.80 (3.09)||36.16 (4.76)|
|Senior (n = 99)||13.49 (2.60)||21.72 (3.79)||35.20 (5.73)|
Perceived Devaluation and Discrimination Scale Scoresa in Participants Who Studied Medical Psychology
|Studied medical psychology (n = 532)||14.01 (2.84)||22.14 (3.45)||36.16 (5.37)|
|Did not study medical psychology (n = 203)||14.02 (3.21)||22.94 (3.93)||36.96 (6.29)|
Perceived Devaluation and Discrimination Scale Scoresa in Participants Who Studied Psychiatry
|Studied psychiatry (n = 119)||13.66 (2.61)||21.50 (3.63)||35.16 (5.52)|
|Did not study psychiatry (n = 616)||14.08 (3.00)||22.53 (3.59)||36.61 (5.65)|