The Positive Effects of Promoting Mental Illness Stigma Awareness

by Amber Forsman, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Bamgbade BA, Ford KH, Barner JC. Impact of a Mental Illness Stigma Awareness Intervention on Pharmacy Student Attitudes and Knowledge. Am J Pharm Educ. 2016; 80(5): Article 80.

Mental illness has been part of recorded history dating back to 400 B.C. in Ancient Greece and described by the physician Hippocrates.¹  The societal stigma that frames the diagnosis of mental illness has varied over time and culture. Pharmacy students, just like other members of society, have been exposed to and influenced by such stigmas. But unlike other members of society, pharmacy students (indeed, all health professions in general) have a special obligation to provide patient-centered care to all individuals, including those with mental illness. Thus, programs that are intended to address misconceptions about and stigma related to mental illness are a critical component of health professions education.  The Impact of a Mental Illness Stigma Awareness Intervention on Pharmacy Student Attitudes and Knowledge is a study conducted at the University of Texas at Austin that provides evidence that a course on mental illness stigma awareness can make a difference by reducing mental health stigma and increasing mental health knowledge.²

In this pre-post study, a stigma awareness program was provided to Doctor of Pharmacy students on select mental illnesses — specifically depression and schizophrenia —over two class periods (2.5 hours total). Participants (n=120) were third-year student pharmacists who had previously completed the mental health pharmacotherapy module in the school’s curriculum.² The mental illness stigma awareness program was provided as part of a required pharmacoeconomics course, but the activity did not count toward the students’ grades in the course.² The stigma awareness program included videos on schizophrenia stereotypes, patient and provider testimony on the impact of stigma in healthcare practices, patient testimony on experiencing depression and schizophrenia, and a documentary of a patient refusing to be treated for schizophrenia.² After students watch each video, the instructors facilitated reflective discussions.² In addition, there were active learning exercises such as schizophrenic hallucination simulations and “Fact or Fiction” exercises. The videos, discussions, and active learning exercises were designed to target specific domains of mental health stigma (MHS): safety, social distance, separation, comfort, disclosure, and recovery. Participants completed anonymous surveys immediately before and after the program using identical instruments.² The pre and post-surveys included questions related to MHS subdomains: recovery, safety, disclosure, separation, and comfort.² Responses to most survey questions were based on a 5-point Likert scale [strongly disagree (1) to strongly agree (5)].² However, the MHS separation subdomain was measured using an 8-item Social Distance Scale and two additional questions derived from the primary literature.^2,3-5 The pre and post-survey also included ten true/false questions to determine the students’ mental health knowledge (MHK).² The MHS data were analyzed using paired t-tests to compare mean scores before and after the program.² The MHK true/false question data (based on answer correctness) was analyzed using McNemar’s tests to compare the accuracy of student’s answers before and after the program.² 

The pre-program survey revealed significant knowledge deficits among students who had already taken a pharmacotherapy module regarding the treatment of various mental illnesses (pre-test MHK mean score = 5.9/10).  Moreover, the MHS subdomain mean scores range of 1.8 to 3.4 suggested that many students have some level of stigma toward individuals with mental illness.²  After completing the program, post-program survey results found the MHK improved significantly and there was diminished stigma towards mental illness.²  See a summary of the study results in Table 1.

Table 1:  Summary of Study Results²

MHS	Overall stigma toward depression and schizophrenia decreased after the mental illness stigma awareness program
	Significant improvements in the (p<0.01) mental illness stigma occurred in the following subdomains: recovery, safety, separation, and comfort stigma.
	There was a significantly greater decrease in stigma subdomains: recovery and separation for schizophrenia when compared to the changes in the recovery and separate subdomains for depression
MHK	MHK significantly increased after the program, with the mean score improving from 5.9 to 6.8 (<0.01).
	Improvements in student knowledge related to pharmacy counseling, outcomes associated with mental illness, and symptomology of mental illness significantly increased (P<0.05)

One strength of this study was the data collection about the students’ personal (including family members) experience with mental illness. This data was valuable because personal experience could impact a student’s responses to the survey. Conversely, a weakness is the limited diversity of the population.  The intervention was conducted and assessed in only one group of students at a single pharmacy school, with only 88 participants completing both the pre and post-survey. In order to get a more precise picture of the benefits of this intervention, it will be necessary to repeat the program in multiple groups of pharmacy students at several schools across the nation, or even internationally. I believe that the methods used in this study were appropriate, especially because the program included several elements (videos, reflective discussion, and active learning exercises), and the survey instruments included validated questions that measure the intended constructs related to MHS.

Similar studies have been conducted at other pharmacy schools.   Consumer- led Mental Health Educations for Pharmacy Student⁶, A Mental Health Elective to Improve Pharmacy Students’ Perspectives on Mental Illness ⁷, and An Elective Psychiatric Course to Reduce Pharmacy Student’s Social Distance Toward People with Severe Mental Illness⁸ all came to a similar conclusion -  that stigma toward individuals with mental illness can be reduced when student pharmacists interact with patients with mental illness and provided instruction regarding mental health.^2,6-8

The fact that student’s biases and knowledge can be positively impacted through an educational program seems like common sense. However, instruction can take many forms and some strategies may be more effective than others.  What I have found in the components of this study and the comparable studies is that the instructional materials used attempt to humanize mental illness in contrast to the textbook-type (detached and unemotional) way pharmacy students most often learn about diseases. Additionally, this study provides evidence that using diverse and engaging materials such as videos, discussions, and active learning exercises can have a positive impact. Moreover, this study provides some helpful insight into how programs intended to address highly stigmatized disease states could be designed and implemented. I sincerely hope that the positive effects observed in this short intervention will positively impact the way these students communicate with and care for their future patients with mental illness.

References

1. WGBH Educational Foundation. Treatments for Mental Illness [Internet]. PBS. Public Broadcasting Service; [cited 2020Sep29].
2. Bamgbade BA, Ford KH, Barner JC. Impact of a Mental Illness Stigma Awareness Intervention on Pharmacy Student Attitudes and Knowledge. Am J Pharm Educ. 2016; 80(5):Article 80.
3. Corrigan PW, Green A, Lundin R, Kubiak MA, Penn DL. Familiarity With and Social Distance From People Who Have Serious Mental Illness. Psychiatric Services. 2001; 52(7): Pages 953–8. [Pub Med]
4. Penn DL, Guynan K, Daily T, Spaulding WD, Garbin CP, Sullivan M. Dispelling the Stigma of Schizophrenia: What Sort of Information Is Best? Schizophrenia Bulletin. 1994; 20(3): Pages 567–78.
5. Link BG, Cullen FT, Frank J, Wozniak JF. The Social Rejection of Former Mental Patients: Understanding Why Labels Matter. American Journal of Sociology. 1987; 92(6): Pages 1461–500.
6. O'Reilly CL, Bell JS, Chen TF. Consumer-led Mental Health Education for Pharmacy Students. Am J Pharm Educ. 2010; 74(9): Article 167.
7. Gable KN, Muhlstadt KL, Celio MA. A Mental Health Elective to Improve Pharmacy Students' Perspectives on Mental Illness. Am J Pharm Educ. 2011;75(2): Article 34.
8. Di Paula BA, Qian J, Mehdizadegan N, Simoni-Wastila L. An Elective Psychiatric Course to Reduce Pharmacy Students’ Social Distance Toward People With Severe Mental Illness. Am J Pharm Educ 2011;75(4): Article 72.