Detecting mental health stigma in medical education: a cross-sectional study of differences in medical students' knowledge, attitudes, and behaviors across six years of training
Keywords:
Stigma; Medical students; Discrimination; Mental health; Education; Stereotype; Public stigmaAbstract
Background: Medical students often face psychological distress, worsened by mental health stigma.
Aims: This study examines how stigma-related knowledge, attitudes, and behaviors evolve over six years of medical education and explores socio-demographic and psychosocial predictors of these changes.
Methods: A cross-sectional study conducted during the 2022/2023 academic year involved 969 medical students, with 527 participants. Tools included the Mental Health Knowledge Schedule (MAKS-I), Community Attitudes to Mental Illness Scale (CAMI-I), and Reported and Intended Behavior Scale (RIBS-I), alongside socio-demographic data.
Results: Findings showed a steady improvement in students’ mental health knowledge, attitudes, and behaviors, especially in the final two years. Academic and clinical experiences played a key role in shaping these views. However, a notable increase in mental health issues was observed in the later years. Positive changes were predicted by factors such as personal or family experiences with mental health issues, being older, and being female.
Conclusions: The study emphasizes the need for integrating mental health education and stigma-reduction strategies throughout medical training. Although attitudes and knowledge improved, the rise in mental health issues underscores the importance of continued support and tailored interventions to enhance the well-being of medical students.
References
1. Goffman E. Stigma: notes on the management of spoiled identity. New York: Simon and Schuster; 1963.
2. Lasalvia A. Lo stigma dei disturbi mentali: guida agli interventi basati sulle evidenze. [Italian]. Roma: Fioriti; 2022.
3. Evans-Lacko S, Gronholm PC, Hankir A, Pingani L, Corrigan P. Practical strategies to fight stigma in mental health. In: Fiorillo A, Volpe U, Bhugra D, eds. Psychiatry in practice. Oxford University Press; 2016. p. 237–56.
4. Gaolaolwe W, Manyedi E, Serapelwane M. Family members' experiences of courtesy stigma associated with mental illness. Health SA Gesondheid. 2023;28:2184. doi: 10.4102/hsag.v28i0.2184
5. Phillips R, Benoit C, Hallgrimsdottir H, Vallance K. Courtesy stigma: a hidden health concern among front-line service providers to sex workers. Sociol Health Illn. 2012;34(5):681–96. doi: 10.1111/j.1467-9566.2011.01410.x
6. Pingani L, Pinelli G, Coriani S, et al. Can a negative religious causal attribution of mental illness affect the phenomenon of public stigma? Ment Health Relig Cult. 2022;25(7):665–81. doi: 10.1080/13674676.2022.2106198
7. Van Brakel WH. Measuring health-related stigma—a literature review. Psychol Health Med. 2006;11(3):307–34. doi: 10.1080/13548500600595160
8. Corrigan PW. Mental health stigma as social attribution: implications for research methods and attitude change. Clin Psychol Sci Pract. 2000;7(1):48–67. doi: 10.1093/clipsy.7.1.48
9. Corrigan PW, Watson AC. Understanding the impact of stigma on people with mental illness. World Psychiatry Off J World Psychiatr Assoc WPA. 2002;1(1):16–20. PMID: 16946807
10. Pingani L, Forghieri M, Ferrari S, et al. Stigma and discrimination toward mental illness: translation and validation of the Italian version of the attribution questionnaire-27 (AQ-27-I). Soc Psychiatry Psychiatr Epidemiol. 2012;47(6):993–9. doi: 10.1007/s00127-011-0407-3
11. Weiner B. An attributional theory of achievement motivation and emotion. Psychol Rev. 1985;92(4):548–73. doi: 10.1037/0033-295X.92.4.548
12. Link BG, Stueve A. Evidence bearing on mental illness as a possible cause of violent behavior. Epidemiol Rev. 1995;17(1):172–81. doi: 10.1093/oxfordjournals.epirev.a036173
13. Corrigan PW, Rao D. On the self-stigma of mental illness: stages, disclosure, and strategies for change. Can J Psychiatry. 2012;57(8):464–9. doi: 10.1177/070674371205700804
14. Lasalvia A, Bonetto C, Bodini L, Yanos PT, Roe D, Lysaker PH. Rinforzo narrativo e terapia cognitiva per l'auto-stigma. Come lo sviluppo di una nuova narrazione di sé e la riformulazione di pensieri disfunzionali può contrastare l'auto-stigma nelle persone con malattia mentale. [Italian]. Roma: Giovanni Fioriti Editore; 2024.
15. Link B. Mental patient status, work, and income: an examination of the effects of a psychiatric label. Am Sociol Rev. 1982;47(2):202–15. PMID: 7091929
16. Clement S, Schauman O, Graham T, et al. What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychol Med. 2015;45(1):11–27. doi: 10.1017/S0033291714000129
17. Perlick DA, Rosenheck RA, Clarkin JF, et al. Stigma as a barrier to recovery: adverse effects of perceived stigma on social adaptation of persons diagnosed with bipolar affective disorder. Psychiatr Serv. 2001;52(12):1627–32. doi: 10.1176/appi.ps.52.12.1627
18. Rees A, Cuthbert C, Shah V, et al. Medical student perceptions of mental illness: a cross-sectional transnational study in two medical schools. BMC Med Educ. 2023;23(1):981. doi: 10.1186/s12909-023-04962-2
19. Knaak S, Mantler E, Szeto A. Mental illness-related stigma in healthcare: barriers to access and care and evidence-based solutions. Healthc Manage Forum. 2017;30(2):111–6. doi: 10.1177/0840470416679413
20. Thornicroft G, Rose D, Kassam A. Discrimination in health care against people with mental illness. Int Rev Psychiatry. 2007;19(2):113–22. doi: 10.1080/09540260701278937
21. Babicki M, Małecka M, Kowalski K, Bogudzińska B, Piotrowski P. Stigma levels toward psychiatric patients among medical students—a worldwide online survey across 65 countries. Front Psychiatry. 2021;12:798909. doi: 10.3389/fpsyt.2021.798909
22. Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA. 2010;304(11):1181. doi: 10.1001/jama.2010.1300
23. Knaak S, Modgill G, Patten SB. Key ingredients of anti-stigma programs for health care providers: a data synthesis of evaluative studies. Can J Psychiatry. 2014;59(1 Suppl):19–26. doi: 10.1177/070674371405901S06
24. Givens JL, Tjia J. Depressed medical students' use of mental health services and barriers to use. Acad Med. 2002;77(9):918–21. doi: 10.1097/00001888-200209000-00024
25. Ay P, Save D, Fidanoglu O. Does stigma concerning mental disorders differ through medical education? A survey among medical students in Istanbul. Soc Psychiatry Psychiatr Epidemiol. 2006;41(1):63–7. doi: 10.1007/s00127-005-0994-y
26. University of Modena and Reggio Emilia. Why UNIMORE? [Internet]. 2024. Available from: https://international.unimore.it/about.html. Accessed 16 Mar 2026.
27. Evans-Lacko S, Little K, Meltzer H, et al. Development and psychometric properties of the Mental Health Knowledge Schedule. Can J Psychiatry. 2010;55(7):440–8. doi: 10.1177/070674371005500707
28. Pingani L, Sampogna G, Evans-Lacko S, Gozzi B, Giallonardo V, Luciano M, et al. How to measure knowledge about mental disorders? Validation of the Italian version of the MAKS. Community Ment Health J. 2019;55(8):1354–61. doi: 10.1007/s10597-019-00416-6
29. Taylor SM, Dear MJ. Scaling community attitudes toward the mentally ill. Schizophr Bull. 1981;7(2):225–40. doi: 10.1093/schbul/7.2.225
30. Buizza C, Pioli R, Ponteri M, et al. Community attitudes towards mental illness and socio-demographic characteristics: an Italian study. Epidemiol Psichiatr Soc. 2005;14(3):154–62. doi: 10.1017/s1121189x00006400
31. Evans-Lacko S, Rose D, Little K, Flach C, Rhydderch D, Henderson C, et al. Development and psychometric properties of the Reported and Intended Behaviour Scale (RIBS): a stigma-related behaviour measure. Epidemiol Psychiatr Sci. 2011;20(3):263–71. doi: 10.1017/s2045796011000308
32. Pingani L, Evans-Lacko S, Luciano M, et al. Psychometric validation of the Italian version of the Reported and Intended Behaviour Scale (RIBS). Epidemiol Psychiatr Sci. 2016;25(5):485–92. doi: 10.1017/S2045796015000633
33. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systematic review and meta-analysis. JAMA. 2016;316(21):2214. doi: 10.1001/jama.2016.17324
34. Boni RADS, Paiva CE, De Oliveira MA, et al. Burnout among medical students during the first years of undergraduate school: prevalence and associated factors. PLOS ONE. 2018;13(3):e0191746. doi: 10.1371/journal.pone.0191746
35. McKerrow I, Carney PA, Caretta-Weyer H, Furnari M, Miller Juve A. Trends in medical students' stress, physical, and emotional health throughout training. Med Educ Online. 2020;25(1):1709278. doi: 10.1080/10872981.2019.1709278
36. Rosal MC, Ockene IS, Ockene JK, et al. A longitudinal study of students' depression at one medical school. Acad Med. 1997;72(6):542–6. doi: 10.1097/00001888-199706000-00022
37. Voltmer E, Köslich-Strumann S, Voltmer JB, Kötter T. Stress and behavior patterns throughout medical education – a six year longitudinal study. BMC Med Educ. 2021;21(1):454. doi: 10.1186/s12909-021-02862-x
38. Clark DC. Vicissitudes of depressed mood during four years of medical school. JAMA J Am Med Assoc. 1988;260(17):2521. doi: 10.1001/jama.1988.03410170069036
39. Maddalena NDCP, Lucchetti ALG, Moutinho ILD, Ezequiel ODS, Lucchetti G. Mental health and quality of life across 6 years of medical training: a year-by-year analysis. Int J Soc Psychiatry. 2024;70(2):298–307. doi: 10.1177/00207640231206061
40. Moreira AR, Oura MJ, Santos P. Stigma about mental disease in Portuguese medical students: a cross-sectional study. BMC Med Educ. 2021;21(1):265. doi: 10.1186/s12909-021-02714-8
41. Brenner LD, Wei H, Sakthivel M, et al. Breaking the silence: a mental health initiative to reduce stigma among medical students. Acad Med. 2023;98(4):458–62. doi: 10.1097/ACM.0000000000005090
42. Poreddi V, Thimmaiah R, Math SB. Attitudes toward people with mental illness among medical students. J Neurosci Rural Pract. 2015;6(03):349–54. doi: 10.4103/0976-3147.154564
43. Márquez-Cervantes E, Romero-Guerra DH, Costilla-Esquivel A. Mental illness attitudes in medical education: assessing the stigma in medical students. Salud Ment. 2023;46(2):105–10. doi: 10.17711/sm.0185-3325.2023.014
44. Bannatyne AJ, Jones C, Craig BM, Jones D, Forrest K. A systematic review of mental health interventions to reduce self-stigma in medical students and doctors. Front Med. 2023;10:1204274. doi: 10.3389/fmed.2023.1204274
45. Stirparo G, Pireddu R, D'Angelo M, Bottignole D, Mazzoli R, Gambolò L. Is mental health worse in medical students than in the general population? A cross-sectional study. Medicina. 2024;60(6):863. doi: 10.3390/medicina60060863
46. Corrigan PW, Michaels PJ, Vega E, et al. Key ingredients to contact-based stigma change: a cross-validation. Psychiatr Rehabil J. 2014;37(1):62–4. doi: 10.1037/prj0000038
47. Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Rüsch N. Challenging the public stigma of mental illness: a meta-analysis of outcome studies. Psychiatr Serv. 2012;63(10):963–73. doi: 10.1176/appi.ps.201100529
48. Angermeyer MC, Matschinger H, Holzinger A. Gender and attitudes towards people with schizophrenia. Results of a representative survey in the Federal Republic of Germany. Int J Soc Psychiatry. 1998;44(2):107–16. doi: 10.1177/002076409804400203
49. Pingani L, Catellani S, Del Vecchio V, et al. Stigma in the context of schools: analysis of the phenomenon of stigma in a population of university students. BMC Psychiatry. 2016;16(1):29. PMID: 26860706
50. Evans-Lacko S, Henderson C, Thornicroft G. Public knowledge, attitudes and behaviour regarding people with mental illness in England 2009-2012. Br J Psychiatry. 2013;202(s55):s51–7. doi: 10.1192/bjp.bp.112.112979
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