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Attitudes of the police towards individuals with a known psychiatric diagnosis

Authors:

Abstract

Background Police officers are increasingly required to respond to incidents involving psychiatric patients. However, few studies have assessed whether the attitude of police officers depends on prior knowledge of their specific psychiatric diagnosis. Our aim was to analyze the effects of psychiatric diagnosis on the behavior of police officers. Methods We utilized the Attribution Questionnaire adapted to the police context to examine the attitudes of 927 officers of the Spanish National Police Force towards persons diagnosed with either schizophrenia or depressive disorder playing the role of somebody in need of assistance, a victim of a crime, a witness, or a suspect in a criminal case. Different socio-demographic variables were also collected. Results Compared to attitudes to individuals with a known psychiatric diagnosis, police officers expressed increased willingness to help psychiatric patients and increased sympathy and attributing to them less responsibility for their actions. They also showed increased feelings of avoidance, reported a greater perception of danger and a greater need for isolation and involuntary treatment. This was especially so in the case of schizophrenia. Stigmatizing attitudes were less apparent when the person was a woman, a veteran officer, or someone with a history of work experience. Conclusions Police officers may hold certain stigmatizing attitudes towards persons with mental illness, particularly schizophrenia, that require special attention, as they may negatively affect police action. We found several factors associated with the persistence of these stigmatizing attitudes among police officers that may guide us when implementing training programs for promoting attitude change, especially at the beginning of an officer’s professional career.
Mengual‑Pujanteetal. BMC Psychiatry (2022) 22:614
https://doi.org/10.1186/s12888‑022‑04234‑1
RESEARCH
Attitudes ofthepolice towardsindividuals
withaknown psychiatric diagnosis
M. Mengual‑Pujante1†, I. Morán‑Sánchez2,3*† , A. Luna‑Ruiz Cabello1 and M. D. Pérez‑Cárceles1
Abstract
Background: Police officers are increasingly required to respond to incidents involving psychiatric patients. However,
few studies have assessed whether the attitude of police officers depends on prior knowledge of their specific psychi‑
atric diagnosis. Our aim was to analyze the effects of psychiatric diagnosis on the behavior of police officers.
Methods: We utilized the Attribution Questionnaire adapted to the police context to examine the attitudes of 927
officers of the Spanish National Police Force towards persons diagnosed with either schizophrenia or depressive dis‑
order playing the role of somebody in need of assistance, a victim of a crime, a witness, or a suspect in a criminal case.
Different socio‑demographic variables were also collected.
Results: Compared to attitudes to individuals with a known psychiatric diagnosis, police officers expressed increased
willingness to help psychiatric patients and increased sympathy and attributing to them less responsibility for their
actions. They also showed increased feelings of avoidance, reported a greater perception of danger and a greater
need for isolation and involuntary treatment. This was especially so in the case of schizophrenia. Stigmatizing atti‑
tudes were less apparent when the person was a woman, a veteran officer, or someone with a history of work
experience.
Conclusions: Police officers may hold certain stigmatizing attitudes towards persons with mental illness, particularly
schizophrenia, that require special attention, as they may negatively affect police action. We found several factors
associated with the persistence of these stigmatizing attitudes among police officers that may guide us when imple‑
menting training programs for promoting attitude change, especially at the beginning of an officer’s professional
career.
Keywords: Stigma, Stereotypes, Police, Schizophrenia, Depression, Forensic psychiatry
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Background
Over the last 20 years, in Spain and in other European
countries, there has been a significant development
and improvement in mental health services as a result
of various health care policy changes. ere has been a
transition from institutional care of people with men-
tal illnesses to family and community-based care. Most
regions in Spain have their own mental health plans that
support social inclusion, independent living, employ-
ment, and human rights [1]. Despite the progress made
in this area, society in general, and even health profes-
sionals themselves, still maintain certain negative atti-
tudes that may lead to the rejection and social isolation
of psychiatric patients [28]. Recent studies suggest that
professional encounters between the police and per-
sons with mental illness have increased considerably in
recent years [911]. For instance, in the United Kingdom,
approximately 2% of incidents reported to the police
Open Access
M Mengual‑Pujante and I Morán‑Sánchez contributed equally to this
manuscript and should be regarded as joint first authors.
*Correspondence: ines.moran@carm.es
2 Cartagena Mental Health Centre, Real St 8, E‑30201, Cartagena, Murcia,
Spain
Full list of author information is available at the end of the article
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Page 2 of 10
Mengual‑Pujanteetal. BMC Psychiatry (2022) 22:614
over a one-year period were linked to mental health
issues [11]. Post deinstitutionalization, police officers are
increasingly required to respond to incidents in the com-
munity involving mentally ill people [10, 12, 13]. Police
officers may identify mental health calls and are often
the first responders in mental health crises [9, 11, 13, 14].
ey play an important role in helping to facilitate access
to appropriate health care and treatment, by partnering
with other emergency medical providers [15]. For exam-
ple, in Spain, transfer protocols have been set up involv-
ing the healthcare services and police officers [16]. ese
include training in advanced communication skills that
assist in the de-escalation of mental health incidents [13].
is leads us to study the attitudes of the police dur-
ing mental health-related encounters since, if these are
negative, they could present an obstacle to the exercise
of the defense of the rights and protection of psychiat-
ric patients. It is for these reasons that, over the last few
years, there has been a growing trend towards assess-
ing stigma among police officers when they encounter
psychiatric patients [17]. Previous studies into this phe-
nomenon mostly reflect that police officers tend to hold
the same points of view about psychiatric patients as
the general population, only somewhat more negative
[13, 17, 18]. For example, Watson etal. found that police
officers often questioned the credibility of patients with
schizophrenia and considered them to be more danger-
ous than people without a mental illness diagnosis. e
label of schizophrenia was also associated with a greater
desire to help, greater sympathy and a lesser inclination
to hold patients with schizophrenia responsible for their
acts [17]. Another study found that police officers, more
than the general public and more than psychiatrists,
perceived psychiatric patients to be unpredictable, dan-
gerous, and difficult to manage. ey also feared them
more than members of the public or psychiatrists [18].
e limitations of these studies include small the sample
sizes, the scarce sociodemographic background informa-
tion, the heterogeneity of assessment instruments and
the undifferentiated role of the psychiatric patient dur-
ing interactions with police officers. On the other hand,
most of these studies assessed attitudes towards only one
type of mental illness, usually schizophrenia, while fail-
ing to explore other common and prevalent disorders
such as depression. Furthermore, most of the research
was carried out in the USA and Canada [1820], and, to
a lesser extent, in Europe [21, 22], which makes it diffi-
cult to extrapolate the results to the Spanish police con-
text. To the best of our knowledge, no previous study
has evaluated police attitudes towards mental illness in
the Spanish context. erefore, we set out to assess how
awareness of a person’s mental illness influences mem-
bers of the Spanish police forces. Our hypothesis was
that mental health stigma would be evident regardless of
the role of the psychiatric patient during the interaction
with police officers. We hypothesized that police offic-
ers would perceive psychiatric patients to be less credible
and more dangerous than someone behaving in an iden-
tical manner but who had not been identified as someone
with a mental illness. We predicted that stigma would be
worse for schizophrenia than for depressive disorder and
it would manifest as a stronger likelihood to isolate the
person and to insist on treatment and, also, to avoid the
person. A further prediction was that the label of men-
tal illness would increase a police officer’s willingness to
help the person, would evoke feelings of sympathy, and
would make the person seem less responsible for his or
her actions.
Methods
Type ofstudy
A cross-sectional study was conducted and approved by
the Research Ethics Committee of the University of Mur-
cia and was authorized by the Training and Development
Division within the Directorate General of the Police.
Participants
e study was conducted at the National Police School
in Ávila, a city in the center of Spain where all the train-
ing courses of the institution take place. Members of
the Spanish police forces who wish to be promoted to a
higher rank must fulfill several requirements, such as
passing a national exam, undergoing a 10-month train-
ing period, and having a certain minimum length of ser-
vice. For example, to be promoted from sub-inspector to
inspector requires a length of service of at least 5 years.
Procedures
e research was carried out according to the instruc-
tions set out in the authorization sent by the Training
and Development Division. Before starting the fieldwork,
several coordination meetings between a member of
the research team and the Heads of Studies of the Span-
ish National Police took place. ose officers who had
attended different training courses during the previ-
ous year were invited to participate by a member of the
research team who explained the study to them during
the training courses. ey carefully reviewed the study
information together and an informed consent form
was signed. e research staff explained that the study
was about police attitudes and decisions and that it was
intended for training purposes – the emphasis on men-
tal illness was not mentioned. e officers who wished to
participate were asked to complete a questionnaire over
a period of one month. At the end of the deadline, all the
questionnaires were collected.
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Mengual‑Pujanteetal. BMC Psychiatry (2022) 22:614
Measurements
Data were gathered from each participant by means of
a questionnaire designed to ascertain the socio-demo-
graphic variables shown in previous research to influ-
ence the attitudes of a police officer toward those with
mental illness: gender, age, educational level, familiarity
with mental illness, and number/frequency of encoun-
ters with mentally ill people [23].
To assess how the stereotype of mental illness may
influence the behavior of the participants, vignettes
designed by Watson et al. were used [17]. Span-
ish translations of these vignettes are available upon
request.ese neutral vignettes describe a hypothetical
subject in the role of a person in different police situ-
ations, i.e., a person in need of assistance, a victim, a
witness, or a suspect. e hypothetical subject, called
Pedro, is described as suffering either from schizophre-
nia or a depressive disorder, or to have no psychiatric
diagnosis. e vignettes do not describe any behavior
or physical description of the fictitious protagonist, as
their aim is to determine whether and how the label
of a mental illness influences the response of police
officers [17]. e vignettes are designed not to por-
tray serious infractions, allowing the police officers
the maximum possible discretion in responding. Oth-
erwise, they would have to act in accordance with the
Spanish criminal code, thereby limiting their responses.
Officers were randomly assigned one of twelve ver-
sions of the survey: one for each of Pedro’s four differ-
ent roles (person in need of assistance, victim, witness,
or suspect), plus label of schizophrenia, depressive dis-
order or no mental illness. We chose those diagnoses
because they are the ones most frequently encountered
by police officers.
Stigmatizing attitudes and beliefs about mental illness
were assessed using the Attribution Questionnaire-27
(AQ-27) designed by Corrigan etal. [24] and modified
by Watson etal. [25]. is tool has been translated into
many languages [2628]. e study used the validated
Spanish version of the modified scale developed by
Muñoz etal. [28]. is self-administered questionnaire
consists of 31 items grouped into nine factors/dimen-
sions, each assessing the following stigma-related con-
structs: responsibility, pity, anger, dangerousness, help,
coercion, segregation, credibility, and avoidance. Partic-
ipants were asked to rate their level of agreement with
each statement on a Likert scale ranging from 1 (“not
at all”) to 5 (“very much”). Each dimension score shows
the mean score of the respective items (the items of
avoidance are reversed in the Spanish version). Higher
scores indicate greater stigmatization.
Statistical analysis
e statistical analysis was conducted using the software
program Stata 17®. P-values < 0.05 were considered to be
statistically significant.
First, we tested normality by P-P plots and homogene-
ity of variances with Levene’s test in order to see if para-
metric tests could be applied. As the assumptions were
met, analysis of variance (ANOVA)/ t test were used.
Second, we described officers´ socio-demographic and
working characteristics. We reported categorical varia-
bles (gender, civil status, education level, professional sta-
tus, age range, encounter frequency and familiarity with
mental illness) as frequencies and valid percentages and
continuous variables (age, length of duty, academy and
previous year training and number of weekly encounters
with mentally ill people) as mean and standard deviations
(SD) for the whole sample. e mean scores and SD of the
scale measuring stigmatizing attitudes and beliefs about
mental illness (the AQ scale) were calculated according
to sociodemographic characteristics. Any sociodemo-
graphic related differences were tested by applying t test
in binary variables, (for example, gender) or by a one-way
ANOVA with post hoc Bonferroni comparisons, in vari-
ables with more than two categories (age range). Correla-
tions between quantitative variables (age, length of duty,
academy and previous year training, number of weekly
encounters with mentally ill people) and AQ scores were
also examined using the Pearson coefficient.
ird, we analyzed differences in stigmatizing attitudes
according to mental illness. Two one-way multivari-
ate analysis of variance (MANOVA) were conducted to
determine if there were any differences between two or
more independent groups of a categorical independent
variable in terms of two or more continuous depend-
ent variables. In the first MANOVA test, the vignette
role, the psychiatric history (yes/no) and the interaction
between them were taken as independent variables and
the nine AQ subscale scores were taken as dependent
variables. In the second MANOVA test, the independent
variables were the vignette roles and the type of mental
illness. To understand which independent groups were
different at the univariate level (where the differences
were between each of the AQ subscales scores sepa-
rately), subsequent ANOVA tests were run.
Four: to test differences in stigmatizing attitudes
according to mental illness, we first looked at the differ-
ences in AQ scores (the dependent variable, a continu-
ous measure) between no mental illness vs mental illness
(independent variable, a qualitative variable) and after-
wards we describe in detail differences between schizo-
phrenia vs. depression by applying a one-way ANOVA
with post hoc Bonferroni comparisons. In the first step
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Mengual‑Pujanteetal. BMC Psychiatry (2022) 22:614
we fused schizophrenia and depression in “mental
illness”.
Five: we analyzed the association between vignette
role and stigmatizing attitudes. To test differences in AQ
scores between the different vignette roles a compara-
tive ANOVA test for each AQ factor was run. In order to
see where the differences occurred, post hoc Bonferroni
comparisons (assistance vs. victim vs. witness vs. sus-
pect), were conducted.
e sample size was calculated applying the statistical
treatment for quantitative variables on finite populations:
for a prevalence of 50%, an error precision of 3.5% and a
confidence level of 95%, the recommended sample would
be 783 subjects. To avoid possible losses, a total of 1090
surveys were handed out, 163 officers refused to partici-
pate (15%); and 927 officers finally completed the study.
Results
e baseline characteristics of the participants are
shown in Table1. e mean age of the officers was 35.5
(SD = 6.68) years, and 82.4% were male. e mean length
of service was 11.26 (SD = 7.15) years. Of the group,
Table 1 Baseline characteristics of participants (n = 927)
SD standard deviation
Category Number of cases Percentage
Gender
Men 764 82.4
Women 163 17.6
Civil status
Single 451 48.7
Married/cohabiting 427 46
Previously married 49 5.3
Educational level
Secondary 46.5 431
University 53.5 496
Professional status
Officer 395 42.6
Sub‑Inspector 240 25.9
Inspector 235 25
Chief Inspector 37 4
Commissioner 20 2.2
1st year executive student 41 4.4
2nd year executive student 22 2.4
Age range
Under 31 218 23.5
31–40 526 56.7
Over 41 183 19.7
Familiarity with mental illness
Yes 668 72.1
No 259 27.9
Encounter frequency
Rarely 452 48.8
Sometimes 309 33.3
Often 169 17.9
Mean (SD)
Age 35.5 (6.68)
Length of duty 11.26 (7.15)
Academy training 10.95 (26.02)
Previous year training 13.11 (18.7)
Weekly encounters with mentally ill people 3.15 (4.00)
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Mengual‑Pujanteetal. BMC Psychiatry (2022) 22:614
72.1% (n = 668) had had previous contact with mentally
ill persons and 51.2% (n = 478) had experienced such
encounters in their professional lives.
e 927 participants completed the modified AQ
questionnaire after reading one of the vignettes. 28.2%
(n = 262) received a vignette of a hypothetical person in
need of assistance, 25.8% (n = 239) a vignette of a vic-
tim, 23.2% (n = 215) a vignette of a witness, and 22.8%
(n = 211) a vignette of a suspect. 34.3% (n = 318) received
a vignette of a person diagnosed with schizophrenia,
32.7% (n = 303) a vignette of a person diagnosed with
depression and, 33.0% (n = 306) received a vignette with
no mention of mental illness.
Association betweensocio‑demographics variables
andAQ scores
When the hypothetical person, Pedro, had a history of
psychiatric illness, we found that female police offic-
ers showed greater feelings of pity and desire to help
than male officers: 3.24 (SD = 0.80) vs. 3.02 (SD = 0.72)
points; (t = 2.81, p = 0.005) and 3.99 (SD = 0.86) vs .
3.77 (SD = 0.84) points; (t = 2.43, p = 0.016), respec-
tively. Younger officers had a greater perception of
danger than older officers: 2.56 (SD = 0.62) vs. 2.52
(SD = 0.61) vs. 2.38 (SD = 0.59) points respectively; F
(2,895) = 5.06, p = 0.007). Post hoc paired Bonferroni
comparison revealed significant differences for officers
under 31 years vs. officers older than 41 years (p = 0.001),
and for officers between 31 and 40 years and older than
41 years (p = 0.001). Officers under 31 years wished to
avoid psychiatric patients less than officers between 31
and 41 years 3.30 (SD = 0.69) vs. 3.32 (SD = 0.69) points
and more than older officers 3.08 (SD = 0.85) points ,
F (2,891) = 4.32, p = 0.001). Post hoc paired Bonfer-
roni comparisons, revealed significant differences for
officers under 31 years vs. officers older than 41 years
(p = 0.002), and between officers between 31 and
41 years and older than 41 years, (p = 0.003). Staff mem-
bers who were more familiar with mental health prob-
lems had more feelings of pity and a desire to help 2.99
(SD = 0.78) vs. 2.83 (SD = 0.79) points; t = 2.70, p = 0.007)
and 3.78 (SD = 0.89) vs. 3.62 (SD = 0.88) points; t = 2.52,
p = 0.012), respectively. Length of service was nega-
tively correlated with desire for avoidance (r = 0.102;
p = 0.02) and perception of dangerousness (r = 0.120;
p < 0.001). We found no other statistically significant
differences.
Association betweenpsychiatric history andAQ scores
according tovignette role
e differences between the AQ dimensions accord-
ing to vignette role and psychiatric history are shown in
Table2. All factors except credibility showed statistically
significant differences for the different vignette roles.
A MANOVA test was conducted to examine the main
and interaction effects of psychiatric history (yes/no)
and vignette role on all subscales of the AQ. e results
indicate significant main effects for psychiatric history
F (7,863) = 9.40, p < 0.001) and vignette role F (3,863)
Table 2 Attribution Questionnaire factor scores according to vignette role and psychiatric history
SD standard deviation
a Student t
Factors Assistance paVictim paWitness paSuspect pa
Responsibility Mean (SD) No mental illness
Mental illness 2.24 (0.68)
2.00 (0.61) 0.007 2.21 (0.56)
2.06 (0.51) 0.069 2.29 (0.62)
2.04 (0.61) 0.008 2.43 (0.67)
2.06 (0.55) < 0.001
Pity
Mean (SD) No mental illness
Mental illness 3.24 (0.60)
3.36 (0.75) 0.16 2.48 (0.81)
2.90 (0.68) < 0.001 2.34 (0.77)
2.96 (0.69) < 0.001 2.62 (0.81)
2.99 (0.76) 0.001
Anger
Mean (SD) No mental illness
Mental illness 1.49 (0.66)
1.57 (0.62) 0.001 1.58 (0.65)
1.85 (0.79) 0.014 1.60 (0.63)
1.72 (0.68) 0.241 1.84 (0.93)
1.83 (0.82) 0.952
Dangerousness
Mean (SD) No mental illness
Mental illness 2.33 (0.55)
2.55 (0.55) 0.003 2.07 (0.63)
2.48 (0.58) < 0.001 2.13 (0.62)
2.34 (0.56) 0.016 2.38 (0.66)
2.66 (0.61) 0.003
Help
Mean (SD) No mental illness
Mental illness 3.96 (0.85)
4.01 (0.84) 0.661 3.50 (0.88)
3.62 (0.87) 0.333 3.29 (1.04)
3.82 (0.82) < 0.001 3.48 (0.89)
3.79 (0.83) 0.014
Coercion
Mean (SD) No mental illness
Mental illness 2.56 (0.85)
3.36 (0.84) < 0.001 2.16 (0.77)
3.01 (0.82) < 0.001 1.88 (0.84)
2.74 (0.92) < 0.001 2.24 (0.88)
3.29 (0.87) < 0.001
Segregation Mean (SD) No mental illness
Mental illness 2.06 (0.69)
3.36 (0.84) < 0.001 1.91 (0.76)
2.49 (0.78) < 0.001 1.69 (0.70)
2.10 (0.74) < 0.001 2.13 (0.85)
2.79 (0.76) < 0.001
Avoidance Mean (SD) No mental illness
Mental illness 3.10 (0.73)
3.26 (0.75) 0.11 2.90 (0.87)
3.27 (0.73) 0.001 2.69 (0.75)
3.09 (0.73) < 0.001 3.33 (0.74)
3.50 (0.75) 0.128
Credibility Mean (SD) No mental illness
Mental illness 3.20 (0.67)
3.15 (0.69) 0.513 2.92 (0.63)
2.81 (0.57) 0.244 3.35 (0.54)
3.23 (0.61) 0.178 2.74 (0.51)
2.72 (0.49) 0.760
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Mengual‑Pujanteetal. BMC Psychiatry (2022) 22:614
=12.06, p < 0.001) but not for the interaction between
them F (3,863) =1.41, p = 0.08.
To test the differences between the questionnaire
constructs according to the vignette role and the type
of mental illness, a MANOVA test was performed. e
results indicate significant main effects for the type of
mental illness F (2,863) =14.36, p <  0.001), and vignette
role F (3,863) =12.79, p < 0.001), but not for the interac-
tion between them F (6,852) =1.14, p =0.222).
Association betweenpsychiatric history andAQ scores
Table3 summarizes the relationship between the modi-
fied AQ scores and psychiatric history. All factors
except for anger and credibility were significantly dif-
ferent. When no background information was available,
the dimensions with the highest overall mean scores
were help and credibility, with 3.58 (SD = 0.95) and 3.06
(SD = 0.64) points, respectively. When the hypothetical
subject had schizophrenia, the dimensions with the high-
est scores were help and avoidance, with a mean score
of 3.82 (SD = 0.82) and 3.31 (SD = 0.74) points, respec-
tively, while anger was the dimension with the lowest
score, with 1.75 (SD = 0.70) points. Police officers showed
more willingness to help and greater feelings of pity and
were less likely to consider psychiatric patients to be
responsible for their actions when compared to Pedro
whose mental health status was unknown (p <  0.001).
ey also showed more reactions of avoidance, consid-
ered mentally ill Pedro to be more dangerous, and saw a
greater need to isolate him and coerce him into receiv-
ing medical treatment (p < 0.001). Post hoc paired Bon-
ferroni comparisons (no mental illness vs schizophrenia
or depression) revealed significant differences for all the
AQ factors except for anger and credibility dimensions.
e comparison between schizophrenia and depression
revealed significant differences for the dangerousness,
coercion, and segregation dimensions (p = 0.038, p = 0.002
and p = 0.011, respectively).
Association betweenvignette role andAQ scores
Table4 shows the modified AQ dimension scores accord-
ing to each hypothetical situation. Help was the construct
with the highest scores while anger had the lowest score.
Comparative one-way ANOVA tests of each factor in the
different vignette roles revealed statistically significant
differences in all AQ dimensions except for the respon-
sibility construct. In order to see where the differences
occurred, post hoc Bonferroni comparisons (assistance
vs. victim vs. witness vs. suspect), were conducted.
Discussion
We believe this study is important because it is the first to
specifically evaluate the phenomenon of evident stigma
associated with mental illness shown among the Spanish
State Security Forces. Since Watsons research into the
phenomenon of stigma in the American police, using the
modified AQ questionnaire [17, 25], no previous study
has applied this tool to the Spanish police, which gives
our research added value.
In step two we analyzed stigmatizing attitudes and
beliefs about mental illness with AQ questionnaire
according to officers’ sociodemographic and working
characteristics. Our findings indicate that female officers
showed more feelings of pity and an increased desire to
help mentally ill people than male officers. ese results
seem to support the conclusions of surveys carried out
among the general population that suggest that women
tend to have less stigmatizing attitudes towards mental
Table 3 Attribution Questionnaire factor scores according to psychiatric diagnosis
SD standard deviation, s schizophrenia, d depression, n no mental illness
* One‑way ANOVA; p < 0.05
* Superscriptsn,d,s indicate Bonferroni post hoc signicant paired comparisons
Factors/N° items Schizophrenia
Mean (SD)
(n= 312)
Depression
Mean (SD)
(n= 302)
No mental illness
Mean (SD)
(n= 290)
P*
Responsibility 2.00 (0.57)n2.08 (0.61)n2.29 (0.64)s,d < 0.001
Pity 3.09 (0.72)n3.04 (0.76)n2.70 (0.82)s,d < 0.001
Anger 1.75 (0.70) 1.72 (0.73) 1.62 (0.73) 0.08
Dangerousness 2.56 (0.58)d,n 2.45 (0.58)s,n 2.24 (0.62)s,d < 0.001
Help 3.82 (0.82)n3.81 (0.88)n3.58 (0.95)s,d < 0.001
Coercion 3.20 (0.85)d,n 3.01 (0.92)s,n 2.22 (0.87)s,d < 0.001
Segregation 2.55 (0.74)d,n 2.37 (0.79)s,n 1.96 (0.77)s,d < 0.001
Avoidance 3.31 (0.74)n3.24 (0.76)n3.01 (0.80)s,d < 0.001
Credibility 2.95(0.63) 3.02(0.64) 3.06 (0.64) 0.102
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 7 of 10
Mengual‑Pujanteetal. BMC Psychiatry (2022) 22:614
illness than men [29]. Younger officers express a greater
perception of danger and an increased desire to avoid
psychiatric patients than older officers. ese findings
are consistent with previous research that suggests that
experienced officers hold relatively less stigmatizing atti-
tudes [22]. In contrast, research carried out among the
general population concludes that older people tend to
have more stigmatizing attitudes [30]. ese differences
may be due to the fact that younger officers, in their
early years in the police force, tend to be more biased
towards psychiatric patients suffering acute symptoms.
ese encounters in crisis situations may produce a mis-
perception of danger, an attitude which may change for
the better over the years after having experienced inter-
actions with mentally ill individuals in a wider range of
situations. We also found that the length of service was
positively correlated with the responsibility dimension
and negatively correlated with avoidance dimension. As
previous studies have shown that training programs may
reduce stigma [14, 3133], we believe that the fact that
experienced officers tend to consider psychiatric patients
to be more responsible for their situation results from a
lack of accurate knowledge about mental illness, as we
included a wide range of variables for length of service
and number of training programs in our sample.
In steps three and four, we analyzed the association
between psychiatric history and stigmatizing attitudes.
Our hypothesis was that mental health stigma would be
evident regardless of the role of the psychiatric patient
during interaction with police officers. MANOVA tests
indicated significant main effects for psychiatric his-
tory and type of mental illness. No significant role-by-
label interaction effects were found, so our hypothesis
that stigma would be present regardless of the role, was
supported. Subsequent ANOVA tests revealed signifi-
cant main effects for psychiatric label on all AQ factors
but the anger and credibility factors. We found increased
desire for avoidance, greater perception of danger, and
a stronger desire to segregate and coerce the psychiatric
patients into receiving medical treatment, so our hypoth-
esis about dangerousness, avoidance, coercion and seg-
regation was supported. In addition, we evaluated the
possible influence of two different disorders (schizophre-
nia and depression) on police encounters. We predicted
that stigma would be worse for schizophrenia than for
depressive disorder and would manifest as a stronger
likelihood to isolate the person and to insist on treatment
and, also, to avoid the person. According to our results,
a diagnosis of schizophrenia increased the perception of
danger and the desire to segregate and to coerce the sub-
ject into receiving medical treatment more than a diag-
nosis of depression. e differences between responses to
schizophrenia and depressive disorder may be explained
by the fact that the stereotype of dangerousness is more
deeply ingrained in schizophrenia than in depression [34,
35]. With respect to the avoidance factor, which is an
indicator of social distance, we found no significant dif-
ferences between the two diagnoses, so our hypothesis
was partially supported. Although the officers showed
more positive attitudes towards depressive disorders,
avoidance behaviors are one of the elements most related
to stigmatization. erefore, according to our findings,
we cannot conclude that a diagnosis of depression always
generates less stigma among police officers than schizo-
phrenia, as studies carried out among the general popula-
tion have suggested [6, 3537].
Scores on dangerousness, coercion, and segregation fac-
tors were higher for psychiatric patients (especially those
Table 4 Attribution Questionnaire factors scores according to the vignette role
SD standard deviation, a assistance, v victim, w witness, s suspect
*One‑way ANOVA
* p < 0.05. Superscriptsa,v,w,s indicate Bonferroni post hoc signicant paired comparisons
Factors,Assistance
Mean (SD)
(n = 262)
Victim
Mean (SD)
(n = 239)
Witness
Mean (SD)
(n = 215)
Suspect
Mean (SD)
(n = 211)
P*
Responsibility 2.08 (0.64) 2.10 (0.58) 2.12 (0.62) 2.19 (0.62) 0.305
Pity 3.31 (0.7) w,s 2.77 (0.74) 2.74 (0.76)a2.86 (0.79)a< 0.001
Anger 1.54 (0.63)v,s 1.77 (0.76)a1.67(0.66) 1.83 (0.79) a< 0.001
Dangerousness 2.47(0.56) w2.35 (0.63) s2.26 (0.58) a,s 2.56 (0.64) a,w < 0.001
Help 3.99 (0.84) v,w,s 3.58 (0.86)a3.64 (0.93)a3.68 (0.86)a< 0.001
Coercion 3.09 (0.92)v,w 2.76 (0.89)a2.44 (0.97)a,s 2.91 (1.00) w< 0.001
Segregation 2.34 (0.70)w,s 2.31 (0.81)w,s 1.95 (0.75)a,v,s 2.55 (0.85)a,v < 0.001
Avoidance 3.20 (0.74)w,s 3.15 (0.79)w,s 2.95 (0.75)a,v,s 3.44 (0.74)a,v,w < 0.001
Credibility 3.16 (0.68)v,s 2.84 (0.59)a,w 3.26 (0.58)s,v 2.72 (0.49)a,w < 0.001
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 8 of 10
Mengual‑Pujanteetal. BMC Psychiatry (2022) 22:614
with schizophrenia), than for individuals whose mental
status is unknown. e result for dangerousness suggests
that this stereotype is intrinsically linked to a diagnosis
of mental illness. Although the information provided
about the type of mental illness and the vignette role
may be different, the perception of dangerousness in the
police context does not vary. ese findings are consist-
ent with those found in various police institutions around
the world, where researchers argue that the most com-
mon police misconception is that all mentally ill people
are dangerous [12, 17, 18, 20, 22, 38]. Unfortunately, the
desire for segregating and coercing a subject into receiv-
ing medical treatment, together with the perception of
dangerousness, may lead police officers to inadvertently
escalate situations by approaching patients with threat-
ening body language and speech, thereby provoking
unnecessary violence in police encounters [17].
Police officers were not likely to experience anger in
mental health-related encounters and they did not con-
sider psychiatric patients to be less credible than some-
one whose mental health status was unknown. Perhaps
the most positive finding to highlight in the compara-
tive analysis between people with and without mental
illness is that our hypothesis about credibility was not
supported: psychiatric history was not associated with
lower perceived credibility. Individuals with a psychiat-
ric diagnosis may be viewed as untrustworthy and unable
to provide reliable information, so they are particularly
vulnerable to victimization [17]. If they seek assistance
from police officers, our findings indicated that they may
be taken seriously and provided with the assistance they
need.
We predicted that the label of mental illness would
increase a police officer’s willingness to help the person,
would evoke feelings of pity, and would make the person
seem less responsible for his or her actions. Our findings
partially supported these hypotheses because in the com-
parative analysis between schizophrenia and depression,
the responsibility dimension did not reveal any signifi-
cant differences. is finding is likely related to whether
an officer is already aware that depressive disorders are in
fact, mental illnesses. One of the greatest problems suf-
fered by people with depression is that they may be con-
sidered weak and responsible for their situation because
of the stereotypes among the general population that
perpetuate this notion [34, 3942].
In general, our results are consistent with those of
Watson [17]. When comparing the scores for each fac-
tor according to whether the person had a mental ill-
ness or not, the differences were low (< 0.5 points),
except for the pity and coercion dimensions, where
Watson etal. obtained lower scores than we did. ese
results could be due to the fact that we included two
types of mental illnesses in our study (schizophrenia
and depression) each of which evokes different degrees
of stigma [35]. e differences in the pity dimension
may highlight police attitudinal changes over time or
cultural differences, as some studies suggest that there
exists less stigma among the Spanish population [43].
In step five, we analyzed the association between
vignette role and stigmatizing attitudes. Interaction
effects of mental illness and vignette role were not sig-
nificant in MANOVA tests. ANOVA results indicated
significant main effects for role on all nine subscales of
the AQ except for responsibility. Help was the construct
with the highest scores in all roles while anger had the
lowest score regardless of the mental status. When
comparing our results with Watson etal., they found
significant differences in responsibility. Our results
seem to support the conclusions of attribution theory
that suggests that emotion (anger or sympathy) medi-
ates cognition (attribution and judgment of responsibil-
ity) and action (helping or punishing behavior) [44, 45].
Police officers may perceive the cause of the situation as
uncontrollable, and judge the person as not responsi-
ble, not experiencing anger, and trying to help the sub-
ject regardless the role he or she is playing.
Some limitations should be considered when inter-
preting our results. e vignettes did not include
certain variables, such as Pedro’s behavior, that are
usually present in daily law enforcement situations.
Further studies should evaluate these results in other
situations more representative of daily police practice.
A second limitation is that we explored the phenom-
enon of stigma with a self-administered questionnaire.
Although these questionnaires have proven to be prac-
tical and cost-effective, with low participant burden,
they have limitations in terms of recall bias and social
desirability bias [46]. In addition, the research was
cross-sectional, so reverse causation and certain degree
of residual confounding cannot be ruled out. Another
limitation arises from the fact that personal factors that
may influence police attitudes have not been controlled
for, as the objective of this study was to assess the influ-
ence of the stigma of mental illness among police offic-
ers. As the results are intended for training purposes,
these unresolved issues should be better assessed in
future studies.
e greatest strength of this research lies in the fact
that it should help to provide valuable information for
improving law enforcement protocols among the Spanish
police forces during interactions with psychiatric patients
and may also help to guide and update police training.
Recent studies carried out among police forces in other
countries have shown that specific training programs
about mental health issues help to reduce stigmatizing
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 10
Mengual‑Pujanteetal. BMC Psychiatry (2022) 22:614
attitudes and increase understanding and support for
people diagnosed with a psychiatric disorder [14, 3133].
Conclusions
Our findings highlight several issues that should be
addressed within the police force. Although police offic-
ers are generally aware of mental illness, they often hold
negative attitudes and beliefs that require attention. Our
study provides evidence that labeling a subject with a
mental illness, especially when the diagnosis is schizo-
phrenia, produces some unwanted effects on decision-
making within law enforcement agencies. We are able to
tease out specific factors that increased stigma and that
will be helpful in the design of police training programs.
We recommend that such training begins early in a police
officer’s career. Patients with a severe psychiatric illness
may be more vulnerable than others when interacting
with the police in the sense that their speech and behav-
iour may be misunderstood [47]. Improving law enforce-
ment training and protocols should be able to reduce
manifestations on the part of police of unwarranted bias
and stigma.
Abbreviations
AQ‑27: Attribution Questionnaire‑27; SD: standard deviation.
Acknowledgments
We would like to thank the Training Division of the National Police Force, the
Spanish Police Foundation, the National Police School and the Center for
Higher Studies for their participation and collaboration.
Authors’ contributions
I.M.S., M. M.‑P., and M.D. P.‑C made substantial contributions to the conception
and design of the work; M. M.‑P., and M.D. P.‑C. performed the analysis and pre‑
pared the Figs. A. L. R.‑C participated in the acquisition of funding. I.M.S. wrote
the main manuscript. All authors reviewed the manuscript and approved the
submitted version.
Funding
This research received no external funding.
Availability of data and materials
The datasets generated and analyzed during the current study are not
publicly available on request from the corresponding author. The data are not
publicly available due to privacy restrictions (include information that allows
the identification of members of the state security forces) but are available
from the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
This study was conducted according to the guidelines of the Declaration
of Helsinki and approved by the Ethics Committee of the UNIVERSITY OF MUR‑
CIA (protocol code 3374 and June 1st, 2021).
All participants gave their informed consent prior to their inclusion in the
study.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1 Department of Legal and Forensic Medicine, Regional Campus of Interna‑
tional Excellence “Campus Mare Nostrum”, Faculty of Medicine, University
of Murcia, Murcia, Spain. 2 Cartagena Mental Health Centre, Real St 8, E‑30201,
Cartagena, Murcia, Spain. 3 Department of Forensic Psychiatry, Law Faculty,
Catholic University of Murcia, Murcia, Spain.
Received: 7 September 2021 Accepted: 17 August 2022
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Background The evidence base for stigma in mental health largely originates from high-income countries. Aims This study from Pakistan aimed to address the gap in literature on stigma from low- and middle-income countries. Method This cross-sectional study surveyed 1470 adults from Karachi, Pakistan. Participants from three groups (healthcare professionals, healthcare students and the general public) completed the adapted Bogardus Social Distance Scale (SDS) as a measure of stigma. Results All three groups reported higher scores of stigma toward mental disorders compared with physical disorders. SDS scores for mental illness in the general public were significantly higher than in healthcare students (mean difference (MD) 6.93, 95% CI 5.45–8.45, P < 0.001) and healthcare professionals (MD 6.93, 95% CI 5.48–8.38, P < 0.001). However, SDS scores between healthcare students and healthcare professionals were not significantly different (MD 0.003, 95% CI −1.14–1.14, P > 0.99). Being female was associated with lower stigma scores and being over the age of 30 years was associated with higher stigma scores. Conclusions Stigma campaigns in Pakistan need to target the general population. However, evidence of negative attitudes toward mental illness in healthcare students and healthcare professionals supports the need for stronger emphasis on psychiatric education within undergraduate and postgraduate training in Pakistan.
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Background: In recent years there is a growing interest in public beliefs about mental disorders. Numerous representative population-based studies have been conducted around the globe, also in European countries bordering on the Mediterranean Sea. However, relatively little is known about public beliefs in countries in Northern Africa. Objective: To fill this gap by comparing public beliefs about mental disorders in Tunisia and Germany, focusing on causal beliefs, help-seeking recommendations and treatment preferences. Methods: Representative national population-based surveys have been conducted in Tunisia in 2012 (N = 811) and in Germany in 2011 (N = 1852), using the same interview mode and the same fully structured interview starting with a vignette depicting a person suffering from either schizophrenia or depression. Results: In Tunisia, the public was more likely to adopt psychosocial and to reject biogenetic explanations than in Germany. Correspondingly, psychological treatments were more frequently recommended and biological ones more frequently advised against. There was also a strong inclination to share religious beliefs and to recommend seeking religious advice. Tunisians tended much more than Germans to hold moralistic views and to blame the afflicted person for his or her illness. In Tunisia, the public tended less to differentiate between schizophrenia and depression than in Germany. Conclusion: Marked differences between Tunisia and Germany exist in public beliefs about the causes of mental disorders and their treatment, which correspond to differences in cultural orientations prevailing in these countries. Mental health professionals need to be sensitive to the particular cultural context in which they operate, in order to be able to reach those they intend to care for.
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Psychiatric emergencies are severe behavioral changes secondary to worsening mental illness. Such situations present a risk to the patient and other people, so they need immediate therapeutic intervention. They are associated with feelings of fear, anger, prejudice, and even exclusion. The attitudes of professionals and factors related to the workplace culture in health can help to perpetuate stereotypes and interfere with the quality of care. Stigma has undesirable consequences in patients with mental disorders. Certain measures can reduce stigma and provide a more dignified way for patients to recover from the crisis. This article aims to discuss the causes of stigma, ways of dealing with it, and achievements that have been made in psychiatric emergency care settings.
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3 Foreword One step forward, two steps back? The European Expert Group on the transition from institutional to community-based care (hereinafter: the "EEG") introduces the Report on the Transition from Institutional Care to Community-Based Services in 27 EU Member States (hereinafter: the "Report" or the "Study"). This Study comes to mark 10 years from the publication of a first important Report 1 , mandated by EU-Commissioner Vladimir Špidla to address the issues of institutional care reform and find solutions for more humane, person-centred, and individualised models of care. In times of the COVID-19 pandemic and lockdowns, this new Report comes at a critical juncture, where the negative aspects of institutionalisation are increasingly blatant and only tend to aggravate with the congregation of a large number of people in one building, and the deprivation of social contacts. The way this crisis is affecting those who need daily care and their support systems stems from structural underinvestment in the inclusion and well-being of all, and in the promotion of different models of support in the community. This is also reflected in the findings of this Report. If nothing changes, the consequences of this crisis are likely to be devastating to the most vulnerable, with long-term consequences on their well-being and development. This Report was commissioned by the European Commission and authored by Jan Šiška and Julie Beadle-Brown, in consultation with the members of the EEG. It offers an insight into how far the transition from institutional to family and community-based care and support has progressed in the past 10 years. It offers a broad picture on situations, solutions and trends in deinstitutionalisation and community-living in the EU for persons with disabilities, with mental health problems, experiencing homeless, children (including children with disabilities and unaccompanied or separated migrant children), and older adults in 27 EU countries 2. The picture drawn in Europe highlights the following trends:  there are still at least 1'438'696 persons living in institutions;  the number of people in institutions does not seem to have substantially changed over the past 10 years;  the number of children in residential care has slightly decreased, with them moving to live with their families, being fostered, adopted, or reaching majority and therefore leaving residential care for children;  in all the 27 EU countries, there are still people living in residential care. Only in a few of them said care is primarily small-scale and community-based, e.g. dispersed among ordinary housing in the general community. Small-scale residential services still represent a minority of the care settings in most of the 27 EU countries;  in some of the countries, people stayed longer in prison and hospitals than needed because of the lack of accommodation in the community, while in others institutional care was the main form of care provision for children without parental care.  in many countries, and especially those who started the process of deinstitutionalisation some time ago persons with intellectual disabilities and complex needs are most likely to still live in institutional settings. Based on these findings, the Report furthermore highlights key concerns and potential solutions that have emerged from its analysis, such as:  The importance of person-centred and individualised support for all, including people with complex support needs, is the only way to ensure full inclusion and participation in the community. The way care is being provided, the quality of support, and their outcomes in terms of quality of life are key indicators.  Although DI is also about the implementation of Article 19 of the UN Convention on the Rights of Persons with Disabilities, there is very little information available on people's lived experiences in terms of choice and control, inclusion, and participation. Understanding the impact of policies on the lives of people should be a key target. Clear definitions, shared terminology, and independent research are fundamental elements to achieve this.
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IntroductionStigma attached to mental health encompasses discrimination and exclusion of psychiatric patients and hinders their opportunities to have more productive and fulfilling lives. Moreover, stigma also exists among health professionals, and therefore, it hampers the provision of treatment and care and the promotion of mental well-being. This manuscript intends to assess and compare the levels of stigmatization toward patients with mental illness between medical students and doctors from different specialties.Methods The Portuguese version of Attribution Questionnaire (AQ-27) was used to assess the attitudes of medical students (n = 203), non-psychiatry doctors (n = 121), and psychiatry specialists (n = 29) from the University of Minho and three hospitals in the region of Braga, Portugal (Hospital de Braga, Hospital Senhora da Oliveira, and Hospital de Fafe).ResultsPsychiatrists were the group that displayed lower levels of stigmatizing attitudes in all the items of the AQ-27, followed by the students. The regression analyses revealed that professional group and presence of a relative with mental illness were the factors that have a significant impact on the levels of stigmatization.Conclusions Mental illness stigma is widely spread in community and reaches not only general population but also health professionals. Psychiatrists presented lower levels of stigma compared with non-psychiatry physicians and medical students. We found that stigma is related with age and the presence of relatives with psychiatric disorders. These findings highlight the critical relevance of raising awareness on this topic and, therefore, break stereotypes to reduce the negative consequences of stigma.
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Persons with mental health problems and/or substance addictions (MHPSA) are stigmatised more than persons with physical conditions. This includes stigmatisation by care professionals. Stigma is considered one of the most important barriers for recovery from these conditions. There is an ongoing debate that use of language can exacerbate or diminish stigmatisation. Therefore, we conducted an experiment examining how four different ways of referring to a person with (a) alcohol addiction, (b) drug addiction, (c) depression and (d) schizophrenia are related to stigmatising attitudes by care professionals in the Netherlands. We partially replicated two studies performed in the United States and used surveys with vignettes containing either ‘disorder-first’, ‘person-first’, ‘victim’ and ‘recovery’ language, which were randomly assigned to participants (n = 361). No significant differences between language conditions were found for any of the vignettes. Our findings suggest that subtle differences in language to refer to persons with mental health problems or substance addictions have no effect on stigmatising attitudes by care professionals in the Netherlands. However, more research is needed to determine the effect of language use on other groups, such as individuals with MHPSA.
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The Crisis Intervention Team (CIT) program was developed as a resource on which police officers could rely when responding to behavioral health calls for service. Baltimore Police Department (BPD) piloted the CIT program in its Central District to address concerns regarding officer attitudes toward and treatment of persons experiencing behavioral health crises. This study used mixed methods to evaluate the effect of the CIT pilot on BPD officer attitudes regarding persons with mental illness and confidence managing behavioral health calls for service. Officer surveys and small group analyses found that Central District officers were more confident handling behavioral health calls for service than Eastern District officers post-pilot. More officers in the pilot district felt better prepared for behavioral health calls for service post-pilot than officers in the control district. Results indicate the CIT program is effective at improving officer confidence and attitude towards responding to behavioral health calls for service.
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