INTRODUCTION AND RATIONALE

Throughout history, the concept of mental illness has changed, going from a magical and supernatural case study initially to the scientific-rational perspective we have today^1,2.

The Royal Spanish Academy defines stigma as: “Disdain, affront and bad reputation”³. In mental health, its impact is twofold: first, personal stigma, such as the prejudice that people with mental illness turn against themselves, and second, social stigma, such as the reaction of the general population towards people with mental illness⁴.

This social stigma is marked by stereotypes, prejudices and discrimination that in a certain way help a majority group to categorise society and quickly identify those they may consider potentially dangerous.

In contrast, “anti-stigma” movements guide their efforts to normalise mental illness, seeking to eradicate stigma and associated discrimination in the media, education, health and labour market^5,6.

Despite these movements and historical development, the stigma surrounding the mentally ill is still there: strange, dangerous, unpredicTable, they generate mistrust and compassion "from a distance". Even health personnel have maintained these beliefs by exercising their profession according to the political and social ideologies of the time^1,7.

It is the patients themselves who report that their mental illness often takes up health care time when they attend primary care services, i.e., their mental illness somewhat eclipses the physical symptoms, losing their organic origin⁸.

Specialised health training, which can be accessed by nurses, psychologists, doctors, pharmacists, physicists, biologists and chemists, includes in its cross-disciplinary training plan courses to increase their bioethical knowledge so as to lead them to act more diligently in their professional sphere⁹. However, in terms of "anti-stigma" education or mental health education in general, a multicentre study evaluating stigma towards people with mental health problems in health science students found that there is a priority for this type of education in nursing and medical students¹⁰. Patients with mental health problems are labelled by health students as deviant, challenging, incompetent, or unable to parent appropriately.

Another Mexican study using the OMI-M scale in psychology students obtained perceptions of aggressiveness and higher scores in areas of social restriction and greater pessimistic prediction of recovery towards people with mental health problems¹¹.

A literature review on stigma towards people diagnosed with borderline personality disorder indicates that both mental health nurses and social workers, psychiatrists or psychologists are a source of harmful attitudes towards people with this type of disorder¹².

The majority of healthcare professionals who participated in a Spanish study conducted in 2017 believed that people with schizophrenia may pose a danger to the rest of the population or to themselves, while acknowledging that these patients do not receive the care they need. The conclusion of the research was that more "anti-stigma" training was needed¹³.

Another factor to consider in relation to stigma towards people with mental health problems is social contact. Previous studies evaluating the effect of combining education with direct or indirect contact found that this is the most effective strategy to improve attitudes and reduce the desire for social distance compared to education alone¹⁴.

Having a family member or friend with a mental health history would also positively influence the healthcare professional's relationship with the patient^15,16.

Currently, there are studies evaluating the degree of stigma in health personnel or in nursing, medicine and psychology students^17,18. However, there is little literature focusing on the attitude of healthcare residents on this issue.

According to a report prepared by the Ministry of Health in 2020, 38.9% of the population in Asturias has a mental health problem¹⁹. Based on this, residents in specialised health training (FSE) of the Principality of Asturias are very likely to have to care for patients with mental health problems throughout their careers.

It is therefore important to evaluate the beliefs, attitudes and behaviours of future specialists towards these patients and to see if they evolve during the residency period. This could help guide specialised health training (FSE) and implement plans and strategies in the field of care in order to provide better care by reducing the stigma of healthcare professionals.

AIM

The aim of the study was to evaluate the degree of stigma of residents in clinical specialities, the "anti-stigma" training received during residency and its influence on the beliefs and attitudes they had in the first and last year of the speciality.

MATERIALS AND METHODS

RESULTS

A total of 144 residents completed the final questionnaire. This represents an overall response rate of 57.6%.

One hundred percent (7/7) of residents with degrees in Clinical Psychology, 67.2% (43/65) in Nursing and 53.1% (94/178) in Medicine responded.

Demographic and speciality variables

The predominant profile was that of a woman (72.2%) with an average age of 28.2 years (SD 3.8) who was in her first year of residence (54.2%). Overall, 51.4% had a medical speciality and 29.9% a nursing speciality. Table 1 shows the absolute and relative frequencies of the sociodemographic data collected.

Table 1. Sociodemographic characteristics (n = 144). 

When asked about their mental health history, 9.0% of residents (n = 13) had or had had a mental disorder. There were 2.8% (n = 4) of residents who did not want to answer. Over half, 54.9% (n = 79), had relatives and/or friends who had or had had a mental disorder. In this item, 8.4% (n=12) did not want to answer.

CAMI-S score and its factors

Table 2 shows the overall mean stigma score and score for the three study factors, with the standard deviation (SD) and 95% confidence interval (95% CI). The results found are associated with favourable “anti-stigma” positions.

Table 2. CAMI-S score (n=144). 

The percentage of residents with scores in the ranges indicating "no stigma" was 77.8% (n = 112) in the factor "integration and contact", 80.6% in "social distance" (n = 116) and 81.9% in "dangerousness and avoidance" (n = 118).

Relationship between stigma and speciality year

In the comparative analysis between the year of speciality and the mean score obtained on the scale and its factors, the differences found were not statistically significant (Table 3).

Table 3. CAMI-S score by year of speciality (n = 144). 

^Note.p < 0.05 was considered statistically significant

Experience and training on social beliefs towards people with mental disorders during specialization

Table 4 shows the relative and absolute frequencies about residents' experience and training on social beliefs towards people with mental disorders.

Table 4. “Anti-stigma” training during specialisation (n = 144). 

^Note:Training modality*. They could answer more than one option.

According to the type of speciality in training, 55.6% (10 out of 18) of residents of the Mental Health speciality received some training and 25.9% (14 out of 54) of residents of Family and Community Care.

Of the 144 residents, 97 (67.4%) believed that general training in psychopathology and/or specific training in stigma would be necessary to improve beliefs and attitudes towards people with mental disorders. Only 1 resident (0.7%) said they did not believe any training was necessary.

At the time of the survey, 137 (95.1%) participating residents replied that during their training and/or working life they had treated someone with mental health problems. This contact positively influenced the beliefs and attitudes of 81 participants (59.1%) and negatively affected 6 participants (4.4%).

Relationship between stigma and training received

When the influence of training on the degree of stigma was assessed, statistically significant differences were obtained in the factors "social distance" and "dangerousness and avoidance" and in the overall CAMI-S score (Table 5).

Table 5. CAMI-S score by training received (n = 142). 

^Note.p < 0.05 was considered statistically significant

^{Note 2:}Participants who did not wish to answer were excluded from the analysis

Relationship between stigma and personal, family or social history of mental disorder

Having had or having a mental disorder did not show any relationship with the total score on the scale or any of its factors (Table 6). This was not the case when there was a family history or social circle of mental disorder, finding statistically significant differences in the factor “integration and contact” (Table 7).

Table 6. CAMI-S score based on personal history (PH) of mental disorder (n = 140). 

^Note.p < 0.05 was considered statistically significant

^{Note 2:}Participants who did not wish to answer were excluded from the analysis

Table 7. CAMI-S score based on family history or social circle of mental disorder (n = 132). 

^Note.p < 0.05 was considered statistically significant

^{Note 2:}Participants who did not wish to answer were excluded from the analysis

DISCUSSION

In response to the objective of this study, the overall mean stigma score in first and last year residents in specialised health training was 86.7 (95% CI: 85.3-88.1). This result is in the upper half of the range of possible CAMI-S scores from 20 to 100, with the highest scores being more favourable reactions to integration.

The average score observed in the subscales “integration and contact”, “social distance” and “dangerousness and avoidance” is included in the score range considered “without stigma”, with the majority of residents located in those ranges. Comparisons with other studies using the CAMI-S scale cannot be made as none were found.

No influence of the speciality year on the degree of stigma was observed. Although training is considered an effective measure to reduce stigma^13,15, only 20.1% of residents had been trained in beliefs towards people with mental disorders during their time in specialisation.

The study confirmed the benefit of this training, since those who received it had lower stigma scores, both overall and in each of the three factors of the CAMI-S scale. However, no statistically significant results were found in the factor "integration and contact", perhaps due to chance, since, observing the confidence interval of the difference of the means, it can be assumed that a larger sample of trained residents would give a different result.

Similar results have been found in other studies, concluding that social distance as an indicator of stigma is lower among professionals who had received "anti-stigma" training^14,15,21. Such training would promote the integration of the mentally ill patient into the community environment and reduce avoidance attitudes and the view of the patient as a dangerous person.

The research carried out showed a better result of stigma when there is a history of relatives or friends with mental disorder, but only on the factor "Integration and contact" and no possible reasons are found to explain it. Prior contact, whether from family or friends with mental illness, positively influences beliefs and attitudes towards these patients¹⁶.

Having a personal history of mental disorder made no difference in stigma. In this respect, the literature consulted does not take a clear position. Some authors claim that there are more favourable and positive attitudes when it is the health personnel themselves who have a personal mental health history¹⁶: they see stigma as unfair and take it as a personal goal of change. However, others point out that some seem to apply prejudice to themselves which negatively affects their self-esteem and self-efficacy by limiting the possibility of counteracting inaccurate stereotypes^22,23.

Healthcare professionals have a duty to perform their functions guided by bioethics and prioritising patient well-being and holistic care, and evidence argues that a lack of mental health training causes an imbalance in this care. Currently in Asturias, more than half of healthcare residents in training care for mental health patients following social constructs more than medicine, nursing and evidence-based psychology²⁴.

There is now an urgent need to include unified and regulated "anti-stigma" training in cross-disciplinary and non-cross-disciplinary training schemes. It's not too late yet, 6 out of 10 residents who are still in their first year of speciality have no training, but can still get it. Not only has this training been found to be effective, but it has shed light on those interventions that have been most effective in reducing the stigma of students and healthcare professionals towards patients with mental illness^16,25.

The lack of a specific training plan that includes content on mental health, and more specifically, on "anti-stigma", in the face of the established need for it, corroborates the low importance and low interest for investment of resources in this health sector²⁶, despite the growing interest it is generating in both public and political media^27,28.

CONCLUSIONS

First- and last-year residents of specialised health training in Asturias have high "anti-stigma" scores for patients diagnosed with mental illness. Although there is no significant change in their beliefs and attitudes towards these patients from the start to the end of their speciality, there is evidence of the benefit of training on a lesser degree of stigma. In addition, the history of family or friends with mental health problems improves residents' view of this group.

It is necessary that the training plan of residents of specialised health training include regulated and unified content in mental health and more specifically in the area of "anti-stigma". This would impact on healthcare providers' view of mental health patients, thereby improving the care provided.