Deepak Prabhakar, M.D., M.P.H.

Department of Psychiatry & Behavioral Neurosciences

Detroit Medical Center/Wayne State University

Detroit, MIe-mail: dprabhakar@med.wayne.edu

Richard Balon, M.D.

University Psychiatric Center

Detroit, MI

Sidney Zisook, M.D.

Dept. of Psychiatry

University of California, San Diego

La Jolla, CA

References

1. Glick ID, Zisook S: The challenge of teaching psychopharma-cology in the new millennium: the role of curricula. AcadPsychiatry 2005; 29:134–140

2. Glick ID, Balon R, Citrome L, et al (eds): Model Psychophar-macology Curriculum For Training Directors and Teachers ofPsychopharmacology in Psychiatric Residency Programs, 6thEd. Glen Oaks, CA, American Society of Clinical Psycho-pharmacology, 2010

3. Zisook S, Balon R, Benjamin S, et al: Psychopharmacologycurriculum field test. Acad Psychiatry 2009; 33:358–363

4. Prabhakar D, Balon R, Deligiannidis K, et al: Módulo endepresión y bipolaridad de la American Society for ClinicalPsychopharmacology.Respondiendo a lanecesidad de unmodeloen la formación. (The American Society for Clinical Psycho-pharmacology’sModules in Depression and Bipolar Disorder:Answering the Call for a Model Curriculum.). Trastornos delÁnimo. 2011; 7:8–13

5. Deligiannidis KM, Girgis RR, Lau A, et al: A psychiatryresident/fellow- initiated and -designed multi-modal psycho-pharmacology curriculum for major depression. Acad Psychi-atry 2012; 36:414–418

Disease Characteristics Should Be Taken IntoAccount When Comparing Attitudes and Levels ofStigma Toward Psychiatric and Medical Conditions

To the Editor: Stigma associated with mental illness maycommonly be encountered in the media (1), among the pub-lic (2), and in professional groups such as physicians (3).Wetherefore read with great interest the article by Korszunet al., which explored medical students’ attitudes towardmental illness (4). The study is commendable and innovative

in two regards, namely, the assessment of attitudinal changewith years of medical school completed and also the explo-ration of the religious and ethnic backgrounds of the res-ponders. Also, although the percentage response rate couldnot be determined because of ethical limitations, the quan-titatively large response of 760 medical students is certainlyhelpful in determining attitudinal differences.

However, we noted, with some concern, several methodo-logical limitations that we believe are important to highlight.The article used a modified version of the Medical ConditionRegard Scale (MCRS) as a tool to compare medical studentattitudes toward severalmedical and psychiatric presentations.Wewere somewhat surprised that themainmedical comparatorto the psychiatric conditions was “pneumococcal pneumonia.”Pneumococcal pneumonia is recognized as the most commoncause of community-acquired pneumonia (5). In the majorityof cases, outpatient treatment with a short course of antibioticswill lead to disease resolution (5). This condition was com-paredwith several presentations thatwere suggestive of severepsychiatric disorders, including “long-standing auditory hal-lucinations and paranoid delusions” and “depression withintermittent suicidal thoughts.” Severe psychiatric disordersdiffer from pneumococcal pneumonia as they are character-istically chronic in nature, following a relapsing–remittingpattern, and are disorders where symptom-reduction is moreoften the goal, rather than complete cure. Furthermore, theadjectives used in describing these psychiatric conditions,such as “long-standing” and with “intermittent suicidalthoughts” may suggest they are particularly severe or com-plex. The description of these active and poorly-controlledsymptoms may also suggest that the underlying psychiatricdisorder is poorly treated or treatment-resistant.

In this context, we believe that medical students should bepresented with chronic medical conditions, which bettermirror psychiatric disorders. Interestingly, the original studydescribing theMCRS incorporated a chronicmedical condi-tion, namely “emphysema from smoking” (6). Emphysemafrom smoking hadmeanMCRS scores suggestive of greaterstigma than almost all of the psychiatric conditions that theoriginal study investigated (6). The mean MCRS score of“emphysema with smoking” in the original study was alsoconsiderably lower than the MCRS scores of all the psychi-atric presentations in all medical student classes in the cur-rent study.

Stigma toward mental illness is commonplace, and, un-fortunately, we have limited resources to overcome it. Com-paring conditions with discordant disease characteristicsmay open the door to biases based on disease course,chronicity, and outcome. It is important to recognize and

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attempt to minimize such biases, as research findings in thisfield may directly affect resource allocation and futureattempts in combating stigma.

Arshya Vahabzadeh, M.D.

Ann C. Schwartz, M.D.

Dept. of Psychiatry

Emory University School of Medicine

Atlanta, GAe-mail: arshya.vahabzadeh@emory.edu

References

1. VahabzadehA,Wittenauer J, Carr E: Stigma, schizophrenia andthe media: exploring changes in the reporting of schizophreniain major U.S. newspapers. J Psychiatr Pract 2011; 17:439–446

2. Evans-Lacko S, Brohan E, Mojtabai R, et al: Association be-tween public views of mental illness and self-stigma amongindividuals with mental illness in 14 European countries. Psy-chol Med 2012; 42:1741–1752

3. Center C, Davis M, Detre T, et al: Confronting depression andsuicide in physicians: a consensus statement. JAMA 2003; 289:3161–3166

4. Korszun A, Dinos S, Ahmed K, et al: Medical student attitudesabout mental illness: does medical-school education reducestigma? Acad Psychiatry 2012; 36:197–204

5. Lynch JP 3rd, Zhanel GG: Streptococcus pneumoniae: doesantimicrobial resistance matter? Semin Respir Crit Care Med2009; 30:210–238

6. Christison GW, Haviland MG, Riggs ML: The Medical Con-dition Regard Scale: measuring reactions to diagnoses. AcadMed 2002; 77:257–262

Response to Prabhakar et al. Letter

To the Editor: Drs. Vahabzadeh and Schwartz make avalid point that certain conclusions cannot be drawn bymaking a comparison between an acute medical condition,such as pneumococcal pneumonia, and chronic mentalhealth disorders. They are also correct that the full MedicalCondition Regard Scale (MCRS) included smoking-related emphysema as one of the medical conditions. How-ever, a comparison between pneumococcal pneumonia andpsychiatric conditions was not the focus of our paper. Wewere interested in exploring how attitudes to psychiatricconditions and medically unexplained physical symptomsmay differ among different groups of medical students, forexample, by age, gender, ethnicity, and stage of studies. Weincluded pneumococcal pneumonia because it is a disorderwith an obvious, external etiology (that even first-year studentswould recognize as such) in order to act as a “positive control.”

Although our results suggest that there has been progressin reducing stigmatizing attitudes to mental health disorderssuch as depression, what is more important for us as educa-tors, is that we do not seem to be changing the attitudesof students, who persist in holding stigmatizing attitudes.Levels of regard toward patients with mental health condi-tions remain similar in final-year medical students, as com-pared with those in first years of the course. Furthermore,there are differences in attitudes between different groups,for example, less tolerance of psychotic symptoms by SouthAsian students, or higher regard for those with depressionin students who have personal experience of mental healthdisorders. However, negative attitudes to medically un-explained symptoms remain highest and appear to deterio-rate over the course of medical studies, and this matter needsto be urgently addressed. Chronic conditions that are not eas-ily remedied may attract more stigmatizing attitudes, reflect-ing frustration, and perhaps an expectation that Medicineshould yield more immediate and satisfying patient recovery.Wewould agree with Drs. Vahabzadeh and Schwartz that

there would probably also be a high degree of stigma asso-ciatedwith smoking-related diseases, but, although this is aninteresting point, it was not the one being investigated in ourstudy. Stigma appears to be associated not only with chronic-ity and failure to respond to treatment, but also with moraljudgments about entitlement to treatment for conditions suchas obesity, smoking, and, perhaps, depression; where theseattitudes are widespread this can also lead to self-stigma. Stig-matizing attitudes that are related to cultural beliefs and valuesinfluence both moral judgments and self-stigma, and theseneed to be taken into account in medical students’ education.

Ania Korszun, Ph.D., M.D., MRCPsych.

Sokratis Dinos, Ph.D.

Barts and The London School of Medicine

Queen Mary University of London

Centre for Psychiatry

London, UK

Kamran Ahmed, M.D.

Postgraduate Department

Maudsley Hospital

London, UK

Kamaldeep S Bhui, M.D., FRCPsych

Basic Medical Sciences

Barts and The London Medical School

Queen Mary, London, UKDr. Korszun; e-mail: a.korszun@qmul.ac.uk

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LETTERS