Journal of Psychiatric and Mental Health Nursing, 2009, 16, 279–284

A study of stigmatized attitudes towards people with

mental health problems among health professionals
H. R A O 1 m b b s m d m r c p s y c h , H . M A H A D E VA P P A 2 m b b s m r c s p s y c h ,
P. P I L L AY 3 m b b s m r c p s y c h , M . S E S S AY 4 m b b s m r c s p s y c h ,
A. ABRAHAM5 mb bs md mrcpsych &
J. LUTY6 mb chb bsc phd mibiol cbiol mrcpsych
1
Specialist Registrar in Psychiatry, Tower Hamlets SAU, Mile end Hospital, London, 2Staff Grade on Old Age
Psychiatry, King’s Wood Centre, Colchester, 4Specialist Registrar in Psychiatry, Dagenham, 5Specialist Registrar in
Psychiatry, Mental Health Unit, Basildon Hospital, Nethermayne, Basildon, 6Consultant in Addictions Psychiatry,
South Essex Partnership NHS Trust, Honorary Consultant in Addictions Psychiatry, Cambridge & Peterborough
Mental Health Partnership NHS Trust, The Taylor Centre, Queensway House, Southend on Sea, Essex, and
3
Senior House Officer in Psychiatry, 15 Elgin House, Cameron Close, Warley, Brentwood, UK

Correspondence: RAO H., MAHADEVAPPA H., PILLAY P., SESSAY M., ABRAHAM A. & LUTY J.
J. Luty (2009) Journal of Psychiatric and Mental Health Nursing 16, 279–284
The Taylor Centre A study of stigmatized attitudes towards people with mental health problems
Queensway House among health professionals
Essex Street
Southend on Sea
The project aimed to assess stigmatized attitudes among health professionals directed
Essex SS1 4RB
towards patients with mental health problems. The Attitude to Mental Illness Questionnaire
UK
was used to assess participants’ attitudes towards fictitious patients from a secure forensic
E-mail: sl006h3607@
blueyonder.co.uk
hospital and patients with schizophrenia and substance use disorders. Participants were
health professionals from acute and mental health settings. In total, 108 completed ques-
tionnaires were received. Participants had highly stigmatized attitudes towards patients
from a forensic hospital and those with active substance use disorders. Attitudes were less
stigmatized to people with substance use disorders who were recovering in remission. This
suggested that health professionals have stigmatized attitudes towards an illness such as
schizophrenia and this is worse towards patients from a secure hospital. The manner in
which patients with substance use disorder are presented can have a significant effect on
stigmatized attitudes by health professionals.

Keywords: discrimination, health professionals, schizophrenia, special hospitals, stigma,

substance use disorders

Accepted for publication: 16 October 2008

2001). Stigmatized attitudes by healthcare staff have been

Introduction
Goffman recognized stigma as a disabling problem for
individuals over 40 years ago (Goffman 1963). More
recently, there has developed a growing literature on stigma
and social exclusion in relation to mental health, especially
when it is perpetrated by health services (Mason et al.
observed particularly in respect to patients with personality
disorder, learning disability and chronic fatigue syndrome.
Epilepsy and HIV are widely recognized to be stigmatizing
conditions although they are not conventionally regarded
as mental illnesses. A case study involving vignettes of
people with alcohol problems showed stigmatized attitudes

© 2009 Blackwell Publishing 279

H. Rao et al.
among psychiatrists who rated the patients as ‘difficult’
‘annoying’ and ‘un-compliant’. Another survey revealed
that 44% of people in London who had experienced
mental distress said they experienced discrimination from
their general practitioners while 35% reported experi-
encing discrimination from other health professionals
(Rethink 2006). The idea that some patients are undeserv-
ing of treatment can translate into discrimination with
some services excluding patients with a diagnosis of per-
sonality disorder (Thornicroft 2006). The careless use of
diagnostic labels has also been identified as a major con-
tribution of the medical professional to the stigma of psy-
chiatric disorders and the World Health Organization has
identified this as a target for its campaign against stigma
(Sartorius 2002). Stigma seems to exist in every area of
life for people with mental illness and represents a major
barrier to effective rehabilitation and reintegration of
these patients (Byrne 2000). Stigma by health professionals
is a particular concern as healthcare services are the
main avenue by which mental health patients are likely to
achieve satisfactory integration into society.
Stigma is a social construction that devalues people as a
result of a distinguishing characteristic or mark (Biernat &
Dovidio 2000). The World Health Organization and World
Psychiatric Association both recognize that the stigma and
discrimination attached to mental disorders are strongly
associated with suffering, disability and poverty (Corrigan
& Watson 2006). The media has generally depicted people
with mental illness as violent, erratic and dangerous (Wahl
1995; Granello et al. 1999). Many studies have shown that
negative attitudes towards people with mental illness are
widespread (Crisp et al. 2005). Discrimination seems to
exist in every area of life particularly for those suffering
with psychosis and drug dependence while shame and
secrecy associated with suffering from a mental illness may
also delay seeking treatment (Byrne 2000). For example,
Docherty (1997) identified stigma as a major barrier to the
management of depression. This view is echoed by the
influential ‘Safer Services’ Report (Appleby 1999) in which
stigma is seen as a major barrier to treatment seeking and
suicide prevention.
Some commentators report concern about stigmatized
and discriminatory attitudes among health professionals
especially in respect to application of the Mental Health
Act (Fleming & Szmuckler 1992, Byrne 2000, Tyrer 2005,
Dein et al. 2007). Hence, the objective of the current study
was to use a validated instrument to assess stigmatized
attitudes among health professionals directed towards
fictitious patients with mental health problems.
We therefore chose to study stigma attitudes towards
the conditions that clearly evoked the most negative
attitudes.
280
Method
Research questions
1. Do health professionals have more stigmatizing
attitudes towards schizophrenia than brief psychotic
episodes?
2. Do health professionals have more stigmatizing atti-
tudes towards patients admitted to a secure hospital
than somebody who has been diagnosed with schizo-
phrenia alone?
3. Do health professionals have more stigmatizing atti-
tudes towards people with active opiate and alcohol
dependencies as compared with those who were cur-
rently abstaining and working?
Participants
Participants were health professionals at four National
Health Service (NHS) trusts in South East England. Two
were mental health trust and two were acute medical trusts
based at district general hospitals. Researchers distributed
invitations between April and August 2007 to staff at these
hospitals and self-completion questionnaires were posted
to those members of staff who volunteered.
Instruments
The five-item Attitude to Mental Illness Questionnaire
(AMIQ) is a brief, self-completion questionnaire (Luty
et al. 2006a; Appendix I). Respondents read a short
vignette describing an imaginary patient and answered five
questions (Appendix I). Individual questions were scored
on a 5-point Likert scale (maximum +2, minimum -2) with
blank questions, ‘neutral’ and ‘don’t know’ scored zero.
The total score for each vignette ranged between -10 and
+10.
The AMIQ was adapted from Cunningham et al. (1993)
and validated in a previous study (Luty et al. 2006b).
Test–retest reliability at 2–4 weeks was 0.702 (Pearson’s
correlation coefficient; n = 256). Internal consistency
(Cronbach’s alpha) was 0.933 (n = 879). Alternate test
reliability compared with Corrigan’s Attributions Ques-
tionnaire was 0.704 (Spearman’s rho; 102; Corrigan
et al. 2003). Other available instruments are much longer,
involve interviews or address the experience of stigma by
the mentally ill, for example, the Internalised Stigma of
Mental Illness scale (Pinfold et al. 2003, Ritsher et al.
2003), Corrigan’s attribution questionnaire (Corrigan
et al. 2003, Crisp et al. 2000).
All participants received vignettes containing reference
to Philip (a fictitious patient admitted briefly to hospital
© 2009 Blackwell Publishing

with an acute psychotic episode), Joshua (a fiction patient
and Michael (a fictitious patient with schizophrenia who
had recently taken an overdose). The vignettes are shown
in Appendix I. These were adapted from a previous study
(Luty et al. 2006a) and were changed to increase the rel-
evance to general hospital staff by introducing the concept
of self-harm.
In a second part of the study, participants were random-
ized to experimental and control groups (computer gener-
ated). This was performed to randomize the possibility of
participants’ prejudices and own attitudes towards drug
addiction. The control groups received simple descriptions
of patients suffering with opiate dependence or alcoholism
(vignettes D and E). The experimental groups received
favourable descriptions of hypothetical patients suffering
with opiate dependence or alcoholism who had returned to
work and stopped drinking (vignettes F and G).
Data analysis
Non-parametric (Mann–Whitney) tests and were used
to compare differences in the two groups using the
Stats Direct statistical package (version 2.4, http://www.
statsdirect.com). The P-value or calculated probability is
the estimated probability of rejecting the null hypothesis of
a study question when that hypothesis is true. Conven-
tional levels of statistical significance are reported where
P < 0.05 or 5% is taken to be statistically significant.
Results
Approximately 200 invitations were issued to health
workers. One hundred and eight completed questionnaires
were received (54%). Respondents had a mean age of 43.2
(SE = 1.2) years; 86% were female; 76% described them-
selves as ‘white British’; they had been working in the NHS
for 14.8 (SE = 0.9) years. 36% worked in an acute hospital
setting; 52% worked in mental health; 58% were qualified
nurses and 13% were healthcare assistants. Some 58%
were qualified nurses and 13% were healthcare assistants.
A total of 9% did not specify any profession. In total, 20%
were doctors.
Results are shown in Tables 1 and 2. There was a sta-
tistically significant difference between the scores for the
patient with the brief psychotic episode and schizophrenia
[median difference obtained through non-parametric
(Mann–Whitney) tests 3; P < 0.0001], indicating a more
stigmatized attitude towards the patient with schizophre-
nia. There was also a significant difference between the
scores for the patient with schizophrenia and the patients
who had previously been admitted to a secure hospital
© 2009 Blackwell Publishing
Stigma health professionals
Table 1
Attitude to Mental Illness Questionnaire (AMIQ) scores for 108
mental health professionals responding to vignettes from
Appendix I (P-values from two-sided Mann–Whitney U-tests)
Vignette AMIQ scores
A – Brief psychotic episode 2.7 (SE = 0.2; n = 108)
B – Special hospital patient -1.2 (SE = 0.3; n = 108)
C – Schizophrenia 0.1 (SE = 0.2; n = 108)
A compared with B – median difference 3; P < 0.0001 (Mann–Whitney)
tests.
B compared with C – median difference 1; P = 0.002.
(median difference 1; P = 0.002), indicating a more stigma-
tized attitude towards the patient from the secure hospital.
Fictitious patients with active opiate dependence and
alcoholism produced a low score, indicating high levels of
stigma among the control group of 54 participants (-1 and
-3 respectively). However, the ratings were considerably
less stigmatized in the experimental group who were asked
to rate more favourable descriptions of these patients who
were abstaining from addictive drugs and working (0.8
and 0.2 respectively). Presenting patients in a more positive
light produced a statistically significant improvement in
scores for both groups (median change >2; P < 0.005).
There was no significant difference between results from
mental health staff and those from other backgrounds.
Of the 108 respondents, 38 (36%) worked in an acute
hospital setting, 56 (52%) worked in mental health and 14
(12%) participants failed to specify.
Giving a breakdown to compare the subset of 38 sub-
jects who worked in acute hospital settings is not helpful
given the small numbers involved. Please see Table 3.
Discussion
Participants were health professionals working in general
medical hospitals and mental health. Although healthcare
staff might be expected to have a more open-minded view
of people with mental health problems, the results indicate
that negative, stigmatized views of people with mental
illness are prevalence even among healthcare workers.
Whereas a number of studies have attempted to assess
stigmatized attitudes among healthcare staff, very few
report on practical methods that can be used to change
these.
Concern about the stigma of mental illness has culmi-
nated in the Royal College of Psychiatrists’ 5-year ‘Chang-
ing Minds’ campaign whose aim was to promote positive
images of mental illness, challenge misrepresentations and
discrimination, encourage patient advocacy and educate
the public to the real nature and treatability of mental
disorder (Crisp et al. 2000). Our study compares well with
the results of Crisp et al.’s (2005) large survey for the
281
H. Rao et al.
Table 2
Attitude to Mental Illness Questionnaire (AMIQ) scores for 108 mental health professionals responding to vignettes from Appendix I (P-values
from two-sided Mann–Whitney U-tests)
Control AMIQ score
Vignette (still using drugs)
Opiate dependent -1.0 (SE = 0.5; n = 50)
D – vignette
Alcoholism -3.0 (SE = 0.5; n = 54)
E – vignette
Table 3
Attitude to Mental Illness Questionnaire (AMIQ) scores for 94 mental health professionals responding to vignettes from Appendix I
AMIQ scores mental health
Vignette staff (n = 56)
A – Brief psychotic episode 3.0 (SE = 0.3)
B – Special hospital patient -1.3 (SE = 0.4)
C – Schizophrenia 0.1 (SE = 0.3)
The results are broken down according to whether the participant worked in mental health or acute hospital.
Changing Minds Campaign which showed that people
with schizophrenia, alcoholism and drug addiction are
the most stigmatized group of all those with mental illness.
For example, 75% endorsed the view that drug addicts
were dangerous to other people compared with 64% for
alcoholism and 66% for schizophrenia. Blameworthiness
was high for drug addiction (60%) and alcoholism (54%)
although it was much lower (under 10%) for other mental
illness (schizophrenia was 6%).
Stigmatizing effect of forensic mental health admission
The results for the vignettes among the health professionals
were highly comparable with the norms reported from over
800 members of the general UK population in the original
validation study for the AMIQ (Luty et al. 2006a). How-
ever, the report here indicates some new data to show that
patients who had previously been admitted to a secure
forensic hospital are subject to more stigmatized attitudes
than other people admitted to hospital with schizophrenia
or a brief psychotic episode. This is consistent with other
research showing that patients of forensic services are even
more stigmatized than general psychiatry patients (Dein
et al. 2007). This is clearly a major problem for this clients
group and needs to be actively addressed – some potential
methods are indicated in the project.
Mechanisms of change and practical significance for
substance use disorders
A large and statistically significant difference in stigmatized
attitudes of two to three units (10–15%) was observed
when hypothetical patients with substance use disorders
were presented positively compared with baseline descrip-
282
Experimental AMIQ score
(abstinent)
0.8 (SE = 0.3; n = 54; D vs. F P = 0.0045)
F – vignette
0.2 (SE = 0.5; n = 54; E vs. G P < 0.0001)
G – vignette
AMIQ scores acute hospital
staff (n = 38)
2.2 (SE = 0.4)
-1.0 (SE = 0.8)
0.1 (SE = 0.3)
tions of patients with active symptoms. The typical scores
observed in the experimental group (0 to +1) remained
significantly less than maximum scores in the original vali-
dation study for non-stigmatized groups like diabetic
patients or practising Christians. Participants scored hypo-
thetical members of these groups around +5. (Range was
-10 to +10 for the AMIQ.) There seems to be a ‘glass
ceiling’ around +1 on AMIQ scale scores above which it is
difficult for any mental health patient to exceed – even
those who have fully recovered.
It could be argued that selectively presenting success
stories of patients who have recovered is simply spin and
would not generalize to other sufferers nor change the
general experience of the mentally ill. However, a major
difficulty with rehabilitation in mental disorder, includ-
ing those with substance use disorders, is to convince
members of the community like employers or landlords
that people can and do recover from mental illness (Sayce
& Boradman 2003). Our study convincingly demon-
strates that the health professionals have a much more
positive attitude towards people who recover from addic-
tive disorders than patients in relapse. Hence, it is worth-
while disseminating examples of successfully recovered
patients to reinforce the idea that treatment works. The
results indicate that it is eminently worthwhile promoting
positive images of people with substance use disorders
in recovery. Whether this can be achieved in respect to
former forensic patients from special hospitals is the
subject of future research. However, vignettes could easily
be developed depicting former forensic psychiatry patients
who have recovered and attempts could also be made to
disseminate this view.
Penn et al. (1999) report a study of 163 US undergradu-
ates who were assigned randomly to four groups to watch
© 2009 Blackwell Publishing

documentaries about schizophrenia (represented a realistic
image), polar bears, being overweight or a no video control
group. The schizophrenia documentary did not change atti-
tudes. Depicting negative consequences of schizophrenia
may be realistic but may not be the best way to reduce
stigma. Hence, the authors state that depicting a success
story may be more effective although subjects may then
classify this as an exception to the rule (Corrigan & Penn
1999).
Many other methods have been suggested to combat the
stigma of mental illness although their effectiveness is often
modest (Knox et al. 2003, Pinfold et al. 2003, Office of
the Deputy Prime Minister 2004, Luty et al. 2007). For
example, promoting direct interpersonal contact with
the mentally ill may be an effective strategy, but how
much contact is required remains unknown (Penn et al.
1994, Wolff et al. 1996, Corrigan & Penn 1999, Pinfold
et al. 2003). However, these methods are time consuming
and require highly motivated participants. Mass media
methods may be more cost-effective, can educate about
most forms of mental illness, and can reach a wider audi-
ence than interviews or direct contact with patients.
Strengths and limitations
The study presented a hypothetical mentally ill person.
This is less accurate than real experience – it was not
possible to measure stigmatized behaviour towards men-
tally ill people. Moreover, the written views and expressed
attitudes may not translate into any enduring behavioural
change. Social desirability bias may also affect the results.
However, the results indicated a very negative view of
people with active substance use disorder and would
suggest that participants had little reservation about indi-
cating their disapproval for these conditions.
Although respondents were health professionals, their
understanding of the terms ‘schizophrenia’ and ‘brief
psychotic episode’ may differ to that used in current
psychiatric practice. Nevertheless, the results do suggest
that ‘schizophrenia’ is a more stigmatized term. Previous
research has indicated that members of the general public
have a reasonably accurate understanding of the term
‘schizophrenia’ and it would be reasonable to expect the
same of other health professionals (Luty et al. 2006b).
Conclusion
Stigmatized attitudes towards people with mental illness
among health professionals are widely prevalent. There
appears to be a greater degree of stigma towards an endur-
ing mental illness such as schizophrenia as compared with
a short lived psychotic episode. A history of detention in
© 2009 Blackwell Publishing
Stigma health professionals
a secure hospital is considered even more stigmatizing.
Among those with problems of drug and alcohol depen-
dents, those who are in treatment and currently abstinent
are seen more favourably than those who are actively
dependent. What interventions if any are effective in chang-
ing some of these attitudes would be an interesting area for
further research.
Acknowledgment
The project was approved by the local Research Ethics
Committees.
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Appendix I Attitudes to Mental Illness
Questionnaire (AMIQ)
Please read the following statement: ‘John has been inject-
ing heroin daily for 1 year’. Please underline the answer
which best reflects your views:
1. Do you think that this would damage John’s career?
Strongly agree-2/Agree-1/Neutral0/Disagree+1/
Strongly disagree+2/Don’t know0
2. I would be comfortable if John was my colleague
at work?
Strongly agree+2/Agree+1/Neutral0/Disagree-1/
Strongly disagree-2/Don’t know0
284
3. I would be comfortable about inviting John to a
dinner party?
Strongly agree+2/Agree+1/Neutral0/Disagree-1/
Strongly disagree-2/Don’t know0
4. How likely do you think it would be for John’s wife
to leave him?
Very likely-2/Quite likely-1/Neutral0/Unlikely+1/Very
unlikely+2/Don’t know0
5. How likely do you think it would be for John to get in
trouble with the law?
Very likely-2/Quite likely-1/Neutral0/Unlikely+1/Very
unlikely+2/Don’t know0
All participants completed the AMIQ for the following
three vignettes:
A. Philip recently had an acute psychotic episode; he was
treated and discharged after a brief hospital admission
1 year ago.
B. Joshua was admitted to the special forensic hospital at
Broadmoor and was discharged 2 years ago.
C. Michael has schizophrenia. He needs an injection of
medication every 2 weeks. He was detained in hospital
for several weeks 2 years ago because he was hearing
voices from the Devil and thought that he had the
power to cause earthquakes. Michael took an overdose
of 50 paracetamol tablets last week when his friend
moved out of the area.
Subjects were randomized into two groups and received
either of the following pairs of vignettes (DE or FG):
Control negative vignettes
D. John was injecting heroin daily for 1 year. John took an
overdose of 50 paracetamol tablets last week after he
received a notice of eviction.
E. Steve has been drinking heavily for 5 years. He usually
drinks more than half a bottle of spirits each day. Steve
took an overdose of 50 paracetamol tablets last week
when he was refused housing benefits.
Positive vignettes
F. John was injecting heroin daily for 1 year. He is now in
treatment and he is not using heroin or any other illegal
drugs. He is working full-time. John took an overdose
of 50 paracetamol tablets last week after he received a
notice of eviction.
G. Steve has been drinking heavily for 5 years. He is going
for treatment and has started attending Alcoholics
Anonymous. He has stopped drinking. Steve took an
overdose of 50 paracetamol tablets last week when he
was refused housing benefits.
© 2009 Blackwell Publishing