A controlled trial of mental illness related stigma training for medical students.

Abstract

The evidence base for mental illness related stigma interventions in health care professionals and trainees is underdeveloped. This study aimed to examine the impact of mental illness related stigma training on third year medical students' knowledge, attitudes and behaviour related to people with mental illness.
A non-randomised controlled trial was conducted with 110 third year medical students at a medical school in England to determine the effectiveness of a mental illness related stigma training package that targeted their knowledge, attitudes and behaviour.
We detected a significant positive effect of factual content and personal testimonies training upon an improvement in knowledge, F(1, 61) = 16.3, p = 0.0002. No such difference was determined with attitudes or for behaviour.
Knowledge, attitudes and behaviour may need to be separately targeted in stigma reduction interventions, and separately assessed. The inter-relationships between these components in mental health promotion and medical education warrant further research. The study next needs to be replicated with larger, representative samples using appropriate evaluation instruments. More intensive training for medical students may also be required.

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RESEARCH ARTICLEOpen Access
A controlled trial of mental illness related stigma
training for medical students
Aliya Kassam1,2*, Nick Glozier1,3, Morven Leese1, Joanne Loughran4and Graham Thornicroft1
Abstract
Background: The evidence base for mental illness related stigma interventions in health care professionals and
trainees is underdeveloped. This study aimed to examine the impact of mental illness related stigma training on
third year medical students’ knowledge, attitudes and behaviour related to people with mental illness.
Methods: A non-randomised controlled trial was conducted with 110 third year medical students at a medical
school in England to determine the effectiveness of a mental illness related stigma training package that targeted
their knowledge, attitudes and behaviour.
Results: We detected a significant positive effect of factual content and personal testimonies training upon an
improvement in knowledge, F(1, 61) = 16.3, p = 0.0002. No such difference was determined with attitudes or for
behaviour.
Conclusions: Knowledge, attitudes and behaviour may need to be separately targeted in stigma reduction
interventions, and separately assessed. The inter-relationships between these components in mental health
promotion and medical education warrant further research. The study next needs to be replicated with larger,
representative samples using appropriate evaluation instruments. More intensive training for medical students may
also be required.
Background
The classical definition of stigma is ‘a trait that is deeply
discrediting that reduces the barer from a whole to a
tainted, discounted one’ [1]. Previous models of stigma
however have had little connection to disability policy
or clinical practice [2]. The concepts of knowledge, atti-
tudes and behaviour, that are relevant to both medical
education [3,4] and health promotion [5,6] can be
applied to the stigma of mental illness [2]. Problems
pertaining to a lack of knowledge constitute ignorance,
and problems in attitudes can be seen as prejudice,
while problems in behaviour may be considered as dis-
crimination. In fact service users often report difficulties
with how healthcare staff treat them such as having
negative attitudes towards people with mental illness,
and by providing a lower standard of care [7-10].
Like the general public, medical students often hold
the stereotypical views that people with mental illness
are unlikely recover and people with severe mental ill-
ness are dangerous and violent [11,12]. It has been
reported that 28% of medical students thought people
with mental illness ‘are not easy to like’ and this rose to
56% at 2 year follow-up. One study found no differences
between medical and nursing undergraduates regarding
their attitudes towards people with schizophrenia [13].
What is notable is that 50% of these medical and nur-
sing students thought that people with schizophrenia
would never recover and 78% considered people with
schizophrenia to be dangerous and violent. Furthermore
95% did not feel they had enough information about
schizophrenia [13]. People with mental illness also have
poorer physical health, in part because of ‘diagnostic
overshadowing’ [14-16] in which the physical problems
of a patient are “over-shadowed” and attributed to their
psychiatric diagnosis [16].
There is growing evidence that mental illness related
stigma can be reduced. Social contact has been shown
to be effective in decreasing negative attitudes about
* Correspondence: kassama@ucalgary.ca
1Section of Community Mental Health Health Service and Population
Research Department, King’s College London, Institute of Psychiatry, De
Crespigny Park, Denmark Hill, London SE5 8AF UK
Full list of author information is available at the end of the article
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© 2011 Kassam et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.

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mental illness [17-19], yet the impact of the psychiatric
clerkship in the medical school curriculum has shown
mixed effects in terms of both favourable and negative
changes in medical students’ attitudes [20-22]. This may
be due to mainly seeing people on the ward who are
very unwell [20-22]. Social contact with a person who
has mental illness has been shown to be an effective
stigma reducing intervention in police officers and
young people [18-22]. Attempts to use a behavioural
component such as communication skills in role-play
training in mental illness related stigma however are
rare. One study examined the effect of role-play training
on attitudes which showed no effect [23] while another
study showed that self-directed role play activity had an
effect on attitudes towards depression [24]. Neither
study measured the effect of such training on the beha-
viour of medical students.
The majority of studies of mental illness related
stigma training in medical students have used either a
lecture delivered by a professional or a non-interactive
video and used evaluation measures that conflated
knowledge and attitudes [25-27]. One study however
investigated didactic teaching versus combined didactic
teaching with self-directed learning using targeted
knowledge and attitude evaluation instruments. The
self-directed learning component incorporated creative
or artistic methods to express their understanding of
depression. The didactic teaching in addition to the self-
directed learning showed greater improvements in
knowledge about depression and improvements in atti-
tudes about depression [24].
Regarding the measurement of attitudes, just as there
are scales assessing medical students’ attitudes towards
people with mental illness before and after a psychiatric
clerkship, scales assessing medical students’ attitudes
towards specialising in the field of psychiatry have also
been developed. This is because there is stigma by asso-
ciation; that is, because the field of psychiatry is respon-
sible for treating people with mental illness, the field
itself also becomes stigmatised. This may lead to psy-
chiatry being a less favoured potential career choice due
to such negative attitudes [28].
The Attitudes Towards Psychiatry (ATP-30) scale [29]
has been used in previous medical student research. In
one study, a significantly negative change was detected
in attitudes of first-year medical students on an anatomy
course as well as with third year paediatric students.
There was a significantly positive change in attitudes
towards psychiatry among third and fourth-year medical
students, but not occupational therapy students who
were exposed to clinical work with patients who had a
mental illness [29].
Another study showed no significant differences
between the pre- and post- attitudinal scores on the
ATP-30 with regards to the sixth-year medical students
who completed the practical psychiatry training [30].
Given these inconsistencies and that the primary focus
of this study was medical students’ attitudes towards
people with mental illness rather than Psychiatry; we
chose not to use this scale. Nevertheless, it must be
emphasized that the ATP-30 does have relevant items
that could be used to determine whether didactic teach-
ing and role play can change knowledge attitudes and
behaviour.
In this study we undertook a controlled trial to com-
pare the effects of 3 different interventions, and directly
assessed students’ mental illness related knowledge, atti-
tudes and behaviour towards people with mental illness.
Methods
Aims
This study aimed to examine the impact of mental ill-
ness related stigma training on third year medical stu-
dents’ knowledge, attitudes and behaviour related to
people with mental illness.
Study design
The study was a non-randomised controlled trial with
three conditions:
A. Control Condition (CC): none of the intervention
elements below.
B. Experimental Condition 1 (EC1): A presentation
on mental illness related stigma which included the
social and personal impacts of stigma against people
with mental illness together with personal testimo-
nies from a mental health service user and a care-
giver of a person with mental illness.
C. Experimental Condition 2 (EC2): As B above plus
a role-play training session in a class room setting
with mental health service user and caregiver
feedback.
We hypothesised that there would be greater, more
favourable change in the knowledge, attitudes and beha-
viour of the experimental conditions (EC1 and EC2)
combined, compared to the control condition (CC).
Furthermore, a greater change would be detected in the
intervention condition that had the factual content, per-
sonal testimonies and role-play training compared to
the condition with just the factual content and personal
testimonies alone.
Sample
Students were recruited before the beginning of their
third year of medicine, which began with a two week
introductory course. All students were given the same
standard training during this two-week course by the
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medical school. Material relating to psychiatry and men-
tal illness during this course was minimal and consisted
of a brief introduction without any contact from service
users or caregivers. Third year medical students were
chosen because at this particular medical school their
psychiatry rotation/clerkship took place in the third year
hence we did not want them to have had clinical con-
tact with patients which could confound the results.
Students were recruited by e-mail. Each student was
sent an email introducing the study and what it would
entail if they chose to participate. A brief presentation
was also given to students at the start of the two-week
course telling them about the study. Students were told
that their participation in the study was entirely volun-
tary and their grades would not be affected in any way
if they chose not to participate. Students who chose to
participate were told that their responses would be kept
anonymous and would not affect their grades or course
work.
At the end of the academic year, data pertaining to
the Psychiatry assessment grades of participants and
non-participants were obtained from the registrar of the
University to which the medical school belonged. Global
scores on the medical school Psychiatry assessments of
the participants and non-participants were used to esti-
mate the representativeness of the sample.
Inclusion/exclusion criteria
Students were included in the trial if they were regis-
tered for their third year of medicine at the medical
school and they: (i) had a valid e-mail address that was
on the list provided by the registrar to the researcher;
(ii) were attending the two week introductory session.
Participants were recruited two weeks prior to the inter-
vention. The recruitment period was short because the
introductory timetable and list of registered students
was not finalised until the start of the two week intro-
ductory period. Students began their psychiatry rotation
immediately after the two week introductory period.
Allocation
Allocation into the trial conditions was done by an
administrator at the medical school blind to the pro-
posed intervention and independent from the research
team. Each trial condition consisted of clusters of firms
which were put together pseudo-randomly by the office
of the registrar. This meant that student groups of six
to ten students were placed together for learning pur-
poses within the medical school curriculum and
remained together throughout the year. The basis for
allocation was whether the clusters of firms had space
in their timetable at the same time when the experimen-
tal condition could take place due to logistical issues at
the medical school. The nature of allocation of students
by the medical school administration, allowing for the
preferences of individual students, was not compatible
with randomisation.
For the evaluation component of knowledge and atti-
tudes, students were contacted by e-mail. For the eva-
luation component of behaviour, a role-play assessment
of communication skills was allocated by the administra-
tor to a subset from each of the conditions (CC, EC1,
EC2) to be examined when they had spaces in their
timetable.
Training intervention
The training intervention was developed separately from
the evaluation team and was developed by a mental
health charity. The interventions were designed to
address the knowledge, attitudes and behaviour model
with the factual component targeting knowledge, perso-
nal testimonies from service users and caregivers target-
ing attitudes and role-play training targeting behaviour.
The intervention in EC1 consisted of a 1-hour time slot
including: (i) a 15 minute factual component presenta-
tion from the mental health promotion officer of the
charity on the social impacts of stigma and discrimina-
tion against people with mental illness including themes
such as healthcare, employment, civil society participa-
tion, personal relationships, medication, media and
aggressive behaviour; (ii) a 15 minute personal testimony
from a mental health service user who was taking medi-
cation for schizoaffective disorder describing their perso-
nal perspectives and experiences of having a mental
illness, stigma and discrimination; and (iii) a 15 minute
personal testimony from a caregiver of a person with
schizophrenia discussing their personal perspectives and
experiences of caring for a person with a mental illness,
stigma and discrimination; (iv) a 10 minute question
and answer session between the students and the mental
service user and caregiver; (v) a 5 minute allotment to
complete a short satisfaction questionnaire about
the entire lecture (factual component and personal
testimonies).
The additional intervention for EC2 was also devel-
oped by the charity. This consisted of two 10-minute
role-play scenarios (a parent and daughter seeking help
for their daughter’s mental health problems and a ser-
vice user who had a physical health complaint). Role-
players were recruited from the role-player company
used by the medical school and were instructed about
the scenario by the researcher. Students were divided
into groups of 8 to 10 and systematically allocated to
different classrooms. A facilitator and either a service
user or caregiver observer were present among the stu-
dents. A student was asked to volunteer for the first
role-play scenario and the role-players were asked to
enter the room by the facilitator. After the role-play, the
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medical students gave their feedback on how they felt
they performed and what they found challenging. This
was followed by the role-players, observing service user
or caregiver and fellow students sharing their feedback
regarding the communication skills used by the medical
student with the role-player(s) in the scenario. This pro-
cess was repeated for the second role-play with a differ-
ent student volunteer. A satisfaction questionnaire was
completed after the role-play training.
Assessments
At baseline the students were asked a number of demo-
graphic factors, social contact of someone with mental
illness and intended area of specialisation after medical
school and had their knowledge and attitudes towards
mental illness evaluated. Students were asked to com-
plete the assessments online two weeks before the inter-
vention (baseline) and were sent reminder e-mails from
the researcher. On the day of, but prior to, the interven-
tion, students also had the opportunity of completing
the instruments in hardcopy. One week after all of the
interventions and role-play assessments were completed,
students were reassessed using baseline measures, either
online or through hard copy. Primary knowledge and
attitude outcome data were obtained from the Knowl-
edge Quiz and the Mental Illness: Clinicians’ Attitudes
(MICA) scale [31]. The secondary outcome measure was
a role-play assessment carried out by the role-players of
which there were no baseline data.
Measures
a) Knowledge: The Knowledge Quiz was designed by the
study team to assess knowledge regarding information
on stigma and discrimination against people with mental
illness. This consists of 10 true or false items based on
key information from current literature and legislation
on areas of prevalence, violence, serving the community,
media, employment, black minority ethnic (BME) issues,
access to healthcare, cost of mental healthcare and the
importance of social networks for people affected by
mental illness. Items generated for the Knowledge Quiz
were reviewed by key researchers in the field of stigma
and mental illness. Although not formally validated it
has both face and content validity with items derived
from sources related to stigma and discrimination in
people with mental illness. The knowledge quiz is
scored in a manner in which a high total score repre-
sents more knowledge about people with mental illness,
stigma and discrimination.
b) Attitudes: Mental Illness: Clinicians’ Attitudes
(MICA) scale The development and validation of the
MICA scale has been described elsewhere [31]. It is
comprised of 16 items with a (1-6) Likert scale. A low
total score (16 minimum) represents less stigmatising
attitudes towards mental illness and psychiatry. The
maximum score on the MICA is 96 showing very stig-
matising attitudes. The MICA scale has satisfactory
internal consistency with a Cronbach’s alpha coefficient
of 0.79 and a test-retest reliability of 0.80.
We felt that meaningful change in knowledge and atti-
tudes corresponds to at least 10% change in the total
mean score although this is somewhat arbitrary given
the nature of this study which was exploratory. In order
to detect a 10% change in the total MICA scale scores
before and after the intervention with 80% power using
a two-tailed test, a minimum of 31 students would be
required at an alpha level of 0.01.
c) Role Play Behaviour: Role play does not necessarily
equate to behaviour. However in medical education,
role-play is often used as a teaching method that is
valued by students in the acquisition of communication
skills. Furthermore, role play promotes active learning
[32]. The role play assessment constituted a list of fif-
teen items pertaining to behaviours (both verbal and
non verbal) that could be interpreted as discriminating
by a person with mental illness or their caregiver. Each
of these items is scored either with a 0, 1 or 2; a higher
score indicating more positive communication beha-
viour and comprised the component score. There was
also a global score for the checklist which was used to
indicate the rater’s overall impression of how the stu-
dent performed. The global score categories were
Excellent = 5, Very good, 4 = Good, 3 = Pass, 2 = Bor-
derline Fail, 1 = Fail. The development and validation
of the role-play assessment was based on an actual
observed structured clinical examination (OSCE) sta-
tion checklist, tailored to issues of stigma with input
from service users and caregivers and is described else-
where [33].
Statistical analysis
Analyses were carried out using only data from students
who completed instruments at both baseline and post-
intervention. Non-completer data were compared to
completers to assess bias. Baseline scores were com-
pared between the arms of the trial, and an analyses of
covariance (ANCOVA) controlling for baseline scores,
gender, and psychiatry assessment grades (from the
medical school at the end of the academic year) was
conducted to estimate differences across the three con-
ditions regarding knowledge and attitudes. For beha-
viour, only a post intervention assessment was available.
Analysis was carried out using regression in STATA
version 10. Residuals from the regressions were exam-
ined for normality. Two pre-specified contrasts were
tested: 1) to compare the two interventions combined
with the control condition, and 2) to compare the two
intervention arms with each other.
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Ethics
This project was approved by the Local Research Ethics
Committee of Bexley and Greenwich (06/Q0707/56) for
the National Health Service in the UK.
Results
Figure 1 shows how the eligibility of the students was
determined from information given by the Medical
School Registrar. The response rates for the primary
outcome instruments are also provided. Of the 408 eligi-
ble medical students, 211 students responded (52%
response rate). However data from 23 were not used
because there were more than 20% of items missing at
baseline and 17 had completed baseline instruments
online after the intervention had taken place as the
online deadline had passed for baseline data collection.
Of the 188 students who completed baseline instru-
ments 110 (59%) had both pre- and post intervention
instruments (Knowledge Quiz and MICA scale) com-
pleted and were used for subsequent analyses. Of the
204 allocated to EC1, 154 attended the lecture and com-
pleted satisfaction questionnaires. Of the 65 of the 204
allocated to EC2, 33 attended the role-play training and
completed satisfaction questionnaires.
The demographic information for the students is
shown in table 1. The majority of the students taking
part were female, of white ethnicity and unsure of what
area of medicine they would specialise in. Nearly half of
the sample personally knew someone with mental ill-
ness. No other data were available for the students.
There was a significant difference between the grades,
with the group of medical students who participated in
Figure 1 Recruitment and follow-up for study. (Note: Baseline = 96+ 58 +34 = 188 Follow-up = 50 + 34 + 26 = 110).
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the study having higher psychiatry assessment scores
than non-participants, 4.3 vs. 4.1, p = 0.008. This shows
that those medical students who chose to take part in
the study either by way of completing baseline instru-
ments, or participating in the intervention conditions
had medical school psychiatry assessment grades that
were significantly higher (more favorable) than those
students who did not participate.
Table 2 shows the mean scores on the Knowledge
Quiz and attitudes before and after the intervention,
and Table 3 shows the adjusted differences between
each of the intervention conditions compared to control
at follow up, controlling for baseline, gender, personally
knowing someone with mental illness and medical
school psychiatry assessment grades.
Knowledge
There were no significant differences in total scores on
the Knowledge Quiz at baseline among the control con-
dition, experimental condition 1 and experimental con-
dition 2 (p = 0.668). At follow up there was a significant
favourable effect of training on knowledge about people
with mental illness and stigma with an adjusted mean
difference of 1.19 (95%CI 0.63-1.76) (comparing the two
interventions combined with control), but no evidence
for a difference between the two different types of
intervention).
Regarding knowledge, the Knowledge Quiz was devel-
oped solely for the purpose of this study; previous data
had not been collected in order to compute a power cal-
culation. A post-hoc power calculation however shows
Table 1 Demographic information for participants in trial
Control Condition (n = 50)Lecture only
(n = 34)
Lecture plus role play (n = 26)
Mean age in years (sd)
22.9 (3.3)22.4 (2.5)22.8 (4.4)
N (%)N (%) N (%)
Male
18 (36) 9 (27) 2 (8)
Ethnicity
White
28 (56) 21 (62)13 (50)
Black
-- 2 (8)
Asian
14 (28)2 (6) 5 (19)
Chinese
3 (6)9 (26) 3 (11)
Mixed
3 (6)2 (6)2 (8)
Other
2 (4)-1 (4)
Intended speciality
Surgery
10 (20)4 (12)3 (11)
General Medicine
4 (8)4 (12)3 (11)
Paediatrics
9 (18)6 (18)1 (4)
Gynaecology/Obstetrics
3 (5) 3 (9)2 (8)
Psychiatry
-2 (6)1 (4)
Laboratory Medicine
--1 (4)
Family Medicine
3 (5)2 (6) -
Public Health
--1 (4)
Other
1 (4)1 (3)1 (4)
Unsure
20 (40)12 (35)13 (50)
Personally knows someone with mental illness
27 (58)19 (53)17 (54)
Table 2 Knowledge and attitude scores for each trial arm.
Control Condition (n = 50)
Mean (sd)
Lecture only
(n = 34)
Mean (sd)
Lecture plus role-play
(n = 26)
Mean (sd)
Total scoreBeforeAfterBeforeAfterBeforeAfter
Knowledge
7.1 (1.5)7.2 (1.5)7.0 (1.4)8.1 (1.2)7.3 (1.4)8.6 (1.1)
Attitudes
38.3 (7.2)38.0 (7.2) 37.4 (5.8)36.3 (5.7)40.3 (8.5)38.6 (7.9)
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that our study had satisfactory power as we had 80%
power to detect a 15.7% change in Knowledge Quiz
scores using a two-tailed test in a sample size of 34 stu-
dents at an alpha level of 0.01.
Attitudes
There was no significant difference between the three
trial arms for attitudes at baseline (p = 0.307). There
was weak evidence (p = 0.085) that any intervention
condition led to less stigmatising scores than the control
condition see Table 3. This was despite achieving ade-
quate samples in the CC and EC1 conditions.
Behaviour
In total, 68 students consented to take part in the role-
play assessments, 22 of whom were from CC, 21 of
whom were from EC1 and 25 of whom were from EC2.
The means (sd) for the global role play scores for CC,
EC1 and EC2 were 3.14 (0.77) 3.52 (0.87) 3.52 (0.77)
respectively. The contrast of the combined experimental
conditions (EC1 and EC2) with the CC was significant
at a borderline significance level, at p = 0.069, but there
was no evidence for a difference between the two inter-
vention conditions.
There were no differences in overall scores when com-
paring the component scores of the service user sce-
nario with the caregiver scenario or when comparing
the global scores of the service user scenario with the
caregiver scenario.
Overall satisfaction with training
Over 80% of the students in the EC1 and EC2 condi-
tions reported that the material in the lecture was clear,
pitched correctly, of relevant content to their medical
education and helped them develop a better understand-
ing of mental illness related stigma. When students were
asked about what they liked best about the lecture, 85%
of students reported the personal testimonies from the
service user and caregiver. Some comments were:
’Patient and caregiver inputs - more useful than text
books/consultant viewpoints.’
’Having people present their own experiences - espe-
cially someone who suffers from a mental health
problem - an excellent way to prove that these people
should not be discriminated against and are actually
very capable.’
’Hearing from someone with a mental illness that I
considered really serious and long lasting and seeing
that he is now just like any other “normal” person.’
Over 70% of the 34 students students who completed
satisfaction questionnaires after the role-play training
reported that the service user and caregiver feedback
regarding the students’ performance during a history
taking was useful and over 80% of students reported
that they felt more confident in speaking to a person
with mental illness or a caregiver of a person with men-
tal illness. When students were asked about what they
liked best about the role-play training, students reported
the service user and caregiver feedback, the opportunity
to practice and learn from the difficult situations raised
in the role-plays. Relevant comments included:
’I feel less intimidated at the prospect of interviewing
a patient in these situations’.
’I think my behaviour would be warm and welcoming
as before but I do feel that I’ve learnt how to speak to
people with mental illness in a better way.’
’An opportunity to explore issues which may arise in
this scenario. Feedback very productive and useful.’
’I already had the attitude that patients with mental
illness required great respect. I still feel this way and
the role-play reinforced this.’
Discussion
The aim of this study was to evaluate (i) whether some
kind of intervention would be effective in changing
knowledge, attitudes and behaviour compared to the
usual medical school curriculum, and (ii) whether the
addition of user and carer enabled role-play training to
a lecture with a factual component with service user
and caregiver personal testimonies was more effective
than the lecture alone.
The lecture sessions, with or without the role playing,
were successful in increasing knowledge in a favourable
direction but there was little evidence that the role-play
Table 3 Comparisons of trial arms (knowledge and attitudes) adjusting for baseline scores1
a) Knowledge Adjusted difference 95% CIp
Interventions (combined) vs. Control-1.192-1.756 to -0.627< 0.001
Lecture vs. Lecture plus role play-0.432 -1.213 to -0.3480.274
b) AttitudesAdjusted difference95% CI p
Interventions (combined) vs. Control-1.569 -3.349 to 0.2190.085
Lecture vs. Lecture plus role play-0.341 -2.828 to 2.1360.785
1gender, medical school psychiatry assessment grades, and personal knowledge of someone with mental illness
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training provided additional impact to the lecture. There
was some weak evidence for the effectiveness of the
combined intervention condition in improving attitudes
and behaviour, but again no evidence for an additional
effect of the role play intervention.
Regarding how representative the sample recruited
was to the rest of the students, there were significant
differences in those medical students who participated
in the study compared to those that did not. This was
expected as participants who would be more interested
in the topic of mental illness related stigma were more
likely to have participated and thus likely to take more
of an interest in psychiatry thereby performing better at
it overall.
Methodological limitations
The study was not randomised as students were allo-
cated to firms by the medical school Registrar and this
determined whether or not they would be given the
intervention since certain clusters of firms had space in
their two week introductory session timetable whereas
others did not. There were two stages at which selection
bais may have occurred. First our participants showed a
gender bias in that female students were over-repre-
sented. Second, the proportion followed up was also
low. While we controlled for some factors associated
with loss to follow up, we were not able to characterise
these completely.
A number of factors may have contributed to the low
follow up rate. We were allowed only one hour for the
lecture intervention with personal perspectives and one
half hour for the role-play training intervention by the
medical school so the instruments were not adminis-
tered within these session times. Students were e-mailed
requesting them to complete the instruments at follow-
up which may have also contributed to the modest fol-
low-up rate and lack of long-term follow-up.
Second, some medical students are keener to learn
than others and view any sort of training and assess-
ment as valuable to their career as a future doctor.
Additionally some medical students may be more inter-
ested in the topic of mental illness related stigma. Given
that psychiatry and mental illness are often stigmatised,
the topic may have not been interesting to other stu-
dents thereby leading to their non-participation in the
follow-up or study overall.
One might surmise that our lack of results may have
been because our participants were already more favour-
ably inclined in terms of attitudes and the intervention
more likely to have an effect on those who did not par-
ticipate. Students knew that the training to be evaluated
was part of a research project and that they would not
be examined on the material of the training. If the train-
ing material and the evaluation were formally embedded
in the curriculum this may have led to more participants
and possibly more observed effectiveness. Much higher
rates have been observed in other settings where this
was the case [24].
Information about student enrolment as well as stu-
dent contact information was provided by the registrar
therefore there may have been discrepancies in the
actual number of students who were eligible as many
students still registered during the two week introduc-
tory session and not all students may have informed the
registrar if they did not attend the two-week introduc-
tory session which was recommended but not compul-
sory. We were conservative in our response rate
estimate since the denominator may have been smaller
than that used.
It must be noted that our results may be biased given
the students were not a representative sample. Partici-
pants were different than non-participants which could
have led to biased results. For example, we may have
not seen a change in attitudes because participants were
already inclined to have positive attitudes. Further, the
change in knowledge may have been detected because
participants were interested in the material. It is also
important to note that the results found may also be
due to the intervention being very short in duration as
the lecture was one hour and the role-play training was
30 minutes while for medical students, a longer inter-
vention may be required however this would need to be
determined in a larger, representative sample.
Effectiveness of training
Despite the relatively small sample sizes and limited
time for intervention, change was detected in knowledge
in medical students who received the experimental con-
ditions. We can be confident that the training was suc-
cessful in leading to greater knowledge amongst these
students than those in the control condition. Changes in
attitudes were promising and warrant further investiga-
tion but not strong enough to be conclusively demon-
strated. There was no evidence that behaviour changed.
This was the first trial with two experimental condi-
tions to examine knowledge, attitudes and behaviour
after mental illness related stigma training in medical
students. Previous studies have either looked at changes
in attitudes after psychiatric clerkships or before or after
mental illness related stigma training without a beha-
vioural component [25-27].
Conclusions
A lecture containing personal testimonies of service
users and caregivers alone was effective in improving
medical students knowledge of the stigma and discrimi-
nation issues of people with mental illness but the role-
play training was not beneficial in further enhancing
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knowledge in the short term. The evidence for these
interventions in improving attitudes and behaviour was
weak and should be interpreted with caution. This find-
ing contributes to the knowledge, attitudes and beha-
viour (skills) paradigm applied in medical education as
well as health promotion. Logistical and implementation
lessons from this trial suggest that both training and
evaluation elements, including assessing knowledge, atti-
tudes and behaviour, need be embedded in medical stu-
dents curriculum and assessments to widen the impact
of these for medical students. Further evaluation of
whether knowledge gains are maintained in the long-
term, the required “intensity” and delivery of interven-
tion [34] and more sophisticated assessment of beha-
vioural change should be the next steps in the research
agenda. Given very recent research showing that people
with mental illness from the same locale as this inter-
vention study lose on average between 8 and 17.5 years
of life through earlier mortality [35] and that access to
life saving interventions is poorer for those with mental
illness [16] such educational initiatives would seem a
prerequisite of good medical education.
Acknowledgements
This trial was part of AK’s PhD thesis which was funded by Lundbeck UK.
This paper also presents independent research commissioned by the
National Institute for Health Research (NIHR) under its Programme Grants for
Applied Research scheme (RP-PG-0606-1053). GT is also funded through a
NIHR Specialist Mental Health Biomedical Research Centre at the Institute of
Psychiatry, King’s College London and the South London and Maudsley NHS
Foundation Trust. The views expressed in this publication are those of the
author(s) and not necessarily those of the NHS, the NIHR or the Department
of Health.
Author details
1Section of Community Mental Health Health Service and Population
Research Department, King’s College London, Institute of Psychiatry, De
Crespigny Park, Denmark Hill, London SE5 8AF UK.2Department of
Community Health Sciences University of Calgary 3rd Floor TRW 3280
Hospital Drive NW, Calgary, T2N 4Z6 Canada.3Discipline of Psychiatry,
Sydney Medical School, The University of Sydney, NSW 2006 Australia.
4Mental Health Promotion, Rethink, Floor 15, 89 Albert Embankment,
London, SE1 7TP UK.
Authors’ contributions
AK carried out the coordination, design and implementation of the trial. NG
supervised AK and provided guidance on the study methodology. JL was
responsible for coordination of the training interventions. ML participated in
the design of the study and performed the statistical analysis. GT
participated in the study design and coordination and helped to draft the
manuscript. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 20 August 2010 Accepted: 29 July 2011
Published: 29 July 2011
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Cite this article as: Kassam et al.: A controlled trial of mental illness
related stigma training for medical students. BMC Medical Education
2011 11:51.
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