COMMISSIONED RESEARCH ON MENTAL HEALTH POLICY AND SERVICES Stigma towards people with psychiatric disorders WWS Mak*, FMC Cheung, SYS Wong, WK Tang, JTF Lau, J Woo, DTF Lee KEY MESSAGES bipolar disorder, depression, alcohol and drug dependence) were adversely affected by public and professional discrimination. Their experienced discrimination and negative perceptions of mental health services reduced their engagement with therapeutic services, intensified their self- stigma, and led to poorer recovery. Hong Kong Med J 2015;21(Suppl 2):S9-12 SMH project number: SMH-14 1. Doctors had the greatest and social workers had the lowest social distance from five disorder groups. Social work students had significantly greater social distance from people with bipolar disorder and schizophrenia than nursing students. People with more severe psychiatric disorders (schizophrenia, bipolar disorder, comorbid psychiatric disorders) had greater self-stigma towards themselves, compared with people having depression or alcohol dependence. 1 WWS Mak *, 1 FMC Cheung, 2 SYS Wong, 3 WK Tang, 2 JTF Lau, 2. Based on the common sense model, professionals' perception of psychiatric disorders contributed to the formation of negative attitude that affected their prognostic predictions and reduced their endorsement of recovery-oriented practice for specific psychiatric disorders. * J Woo, * DTF Lee 1 Department of Psychology, The Chinese University of Hong Kong 2 School of Public Health and Primary Care, The Chinese University of Hong Kong 3 Department of Psychiatry, The Chinese University of Hong Kong 4 Faculty of Medicine, The Chinese University of Hong Kong 3. People with psychiatric disorders (schizophrenia, * Principal applicant and corresponding author: wwsmak@psy.cuhk.edu.hk Introduction Psychiatric disorders (such as schizophrenia, bipolar disorder and depression, alcohol and drug dependence) increase years of life with disability. People with psychiatric disorder often are reluctant to seek help, as they experience stigma while visiting medical or human services. Stigma refers to the endorsement of prejudicial attitudes, negative emotional responses, discriminatory behaviour, and biased social structures towards a subgroup. Stigma not only delays or reduces adherence to treatment and increases dropouts, it also contributes to increased self-stigma and poorer psychosocial outcome. Nursing and medical students, nurses, and doctors were found to have greater levels of stigma and less optimistic prognoses towards people with psychiatric disorders than the general public. Nurses in Beijing and nursing students in Hong Kong also reported greater social distance from people with psychiatric disorders. In Hong Kong, most studies were confined to schizophrenia and depression; no study examined underlying mechanisms of stigma from professionals. The common sense model (CSM) was used to demonstrate how individual perception of psychiatric disorders impacts the way such illness is appraised. Development of stigma is related to prognostic decisions of the professionals and students, and service engagement and recovery outcomes of people with psychiatric disorders. This study aimed to (1) examine the illness perceptions and extent of stigma among students and professionals towards five types of psychiatric disorder; (2) apply the CSM to professionals and students by testing the effects of their illness perceptions on their attitudes, prognostic predictions, and management decisions towards people with psychiatric disorders, accounting for their recovery knowledge; (3) examine the extent of and to test how their experienced discrimination self-stigma among people with psychiatric disorders by professionals and the public and their perceived service orientation of the professionals may impact their self-stigma, service engagement, and recovery, controlling for their symptom severity; and (4) apply the CSM to people with psychiatric disorders by testing the effects of their own illness perceptions on their self-stigma and recovery. This study enabled development of a conceptual model of stigma to explain stigma formation and the impact of stigma on treatment decisions and patient recovery. Methods This study was conducted from August 2010 to July 2012. Informed consent was obtained from each participant. A total of 1143 students (meanstandard deviation [SD] age, 224 years) of various social work, nursing, and medical programmes were recruited through mass e-mails (78%, 78%, and 53% were females respectively) and randomised to two of the five vignettes describing schizophrenia (n=440), Hong Kong Med J | Volume 21 Number 2 (Supplement 2) | April 2015 | www.hkmj.org 9 * Mak et al bipolar disorder (n=434), depression (n=470), alcohol perception of psychiatric disorders with their dependence (n=478), or drug dependence (n=464). attitude, prognostic prediction, and service In addition, 3064 registered professionals (meanSD orientation. The model was a satisfactory fit for age, 3810 years) from the respective programmes (73%, 88%, 41% were females respectively) were recruited from three waves of invitation mails and randomised to one of the five vignettes in the numbers of 607, 641, 556, 634, and 626, respectively. A HK$50 coupon was given upon receipt of a completed questionnaire. The overall response rate for professionals was 16%, compatible with other surveys.5 Upon reading the vignette, respondents were asked to rate their perceived causes, timeline, consequence, personal and treatment control, illness coherence, and emotional representations of the depicted character's disorder based on the CSM and to complete a set of questionnaires. A total of 376 patients (meanSD age, 4313 years) with schizophrenia (n=73), bipolar disorder (n=60), depression (n=75), alcohol dependence (n=60), drug dependence (n=60), or comorbid diagnoses (n=48) for a meanSD of 78 years were recruited from public specialist out-patient clinics and substance abuse assessment clinics and asked to complete a self-report questionnaire. Upon completion, a HK$100 coupon was given. For professionals and students, the questionnaires included Brief Illness Perception Questionnaire, Perceived Devaluation and Discrimination Scale, Social Distance Scale, Psychosocial Outcome scale, a self-developed recovery-oriented case management scale, and the Recovery Knowledge Inventory. For people with psychiatric disorders, the questionnaires included Brief Illness Perception Questionnaire, Perceived Devaluation and Discrimination Scale, Social Distance Scale, Self-Stigma Scale, Service Engagement Scale, Behaviour and Symptom Identification Scale, Life Satisfaction Scale, and the Recovery Markers Questionnaire. Results Social distance of professionals from disorder groups Multivariate analysis of variance was used to examine the social distance of professionals from the five disorder groups. Doctors consistently showed the greatest and social workers the least social distance from the five disorder groups. Social work students exhibited significantly greater social distance from people with bipolar disorder or schizophrenia than nursing students (Table 1). Student and professional perceptions and devaluation model for people with psychiatric disorders Structural equation modelling was used to evaluate the association of students' and professionals' students (X (896)=2116.90, P nursing > social work Social work > nursing Nursing 186 2.650.05 203 Social work 154 2.230.05 185 2.310.05 2.570.06 Medical 201 2.820.05 52 2.390.11 (b) Perceived stigma and self-stigma Perceived discrimination and devaluation Schizophrenia and other psychotic disorders Depression Bipolar disorder Drug dependence/abuse Alcohol dependence/abuse Co-morbidity Social distance with health professionals Schizophrenia and other psychotic disorders Depression Bipolar disorder Drug dependence/abuse Alcohol dependence/abuse Co-morbidity Self-stigma Schizophrenia and other psychotic disorders Depression Bipolar disorder Drug dependence/abuse Alcohol dependence/abuse Co-morbidity No. People with psychiatric disorders MeanSD score Strongly disagree=1 to strongly agree=6 3.320.11 Significant difference between groups (P depression Alcohol dependence/abuse > bipolar disorder Alcohol dependence/abuse > Depression, bipolar disorder Schizophrenia > depression, alcohol dependence/abuse 75 48 73 g22 2.430.08 2.560.09 Bipolar disorder > alcohol dependence/abuse 2.490.09 2.300.09 2.550.10 Co-morbidity > alcohol dependence/abuse Hong Kong Med J | Volume 21 Number 2 (Supplement 2) | April 2015 | www.hkmj.org 11 * Mak et al Consequence Timeline Personal control Treatment control Devaluation Identity Concern Coherence Emotional representation Recovery knowledge Positive life prospects Perceived dangerousness Recovery- oriented practices FIG I. Professionals' and students' perception and devaluation model for people with psychiatric disorders Experienced discrimination (general public) 0.09 0.38 (P