Public Stigma in China Associated With Schizophrenia, Depression, Attenuated Psychosis Syndrome, and Psychosis-Like Experiences

Among people with mental illness, stigma has adverse effects in multiple domains—from detection to treatment and recovery (1–3). Antistigma and public awareness programs have been conducted to minimize the impact of public stigma on patients and their families, but the effectiveness of such programs has been questioned (4,5). With the recent emphasis on detecting and treating individuals in the prodromal phase of psychosis, concerns have been raised about whether stigma would spread to this at-risk population. Attenuated psychosis syndrome (APS), which is characterized by psychosis-like symptoms that are below the threshold for full psychosis, is included in DSM-5 under “conditions for further study.” Scholars continue to debate whether the condition should be classified as a separate diagnostic entity and whether the risk of developing full-blown psychosis and the level of stigma associated with APS are as substantial as they were thought to be (6,7).

Schizophrenia has been viewed as a more stigmatized mental illness than depression (8–10). Many people believe that schizophrenia is a brain disorder and that it is harder to control, more unpredictable, and more dangerous than depression and less likely to be treated (9,11,12). In contrast, many view depression as easier to control than schizophrenia, more predictable, less dangerous, and more treatable; people are less likely to want to maintain social distance from individuals with depression (13). Severity of symptoms and deviation from normal behavior may also affect stigma (14–16).

These explanations of the effects of stigma may apply only when the illness is clearly understood. In the case of APS, people may not fully understand the condition, which may affect their attitude toward the affected individual (17). The symptoms of APS and schizophrenia are similar. Even though APS symptoms are less severe, people might base their understanding of APS on their knowledge of psychosis. This study compared public stigma associated with APS and with schizophrenia, depression, and psychosis-like experiences. We hypothesized that public stigma associated with APS is less than that associated with schizophrenia and similar to that associated with depression and that public stigma is lower among individuals with more education and previous contact with persons with mental disorders.

Methods

Study Design

This cross-sectional study of public stigma used a vignette methodology. A total of 204 Chinese participants were recruited through a public awareness campaign and through the e-mail network of the University of Hong Kong. Individuals age 18 and older who had never had a diagnosis of or treatment for a mental disorder and who consented to participate were included. The study was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster and performed in accordance with ethical standards of the 1964 Declaration of Helsinki and its later amendments. Basic demographic information, including age, gender, current occupation, and education level, was collected. Previous contact with persons with mental illness was also noted on the basis of questions adapted from Alexander and Link (18). Participants read four vignettes describing individuals with APS, schizophrenia, depression, or psychosis-like experiences and responded online. They used a seven-domain stigma scale (SDSS) to rate their level of public stigma associated with each of the four individuals in the vignettes. [The four vignettes are included in an online supplement to this article.]

Measures

Each of the vignettes objectively described symptoms and functioning of the person with the disorder. The schizophrenia and depression vignettes stated the diagnosis and were previously used in study by Pescosolido and colleagues (19). The APS vignette described the likelihood of transition to psychosis as follows: “People at high risk of psychosis have not yet developed a full psychotic disorder but have some symptoms that might lead to a future psychotic disorder. However, only 35% of these individuals will go on to exhibit psychosis within 2.5 years of identification” (20). The vignette on psychosis-like experiences described a person with no psychiatric diagnosis and normal functioning who experienced transient psychotic symptoms. English versions of the Chinese vignettes were back-translated by a professional translator and proved to be satisfactory.

The SDSS is a 27-item questionnaire about public stigma adopted from Pescosolido and colleagues (19). The scale measures seven major domains of public stigma, including social distance, traditional prejudice, exclusionary sentiments, negative affect, perceptions of dangerousness, treatment carryover, and disclosure carryover. Social distance refers to reluctance to interact with members of a group. Traditional prejudice refers to adherence to the belief that all members of a group are categorically inferior to others. Exclusionary sentiment refers to the willingness to exclude people from a group from the full benefits of citizenship. Negative affect refers to public views that people from a group are difficult to interact with. Perception of dangerousness is about the fear that persons from a group represent a threat of violence to self or others. Treatment carryover is the belief that being known to have received mental health care carries long-lasting consequences. Disclosure spillover refers to the negative consequences of revealing one’s mental illness. The SDSS uses a 4-point Likert scale (1, strongly agree; 2, agree; 3, disagree; and 4, strongly disagree) to measure agreement with statements about each vignette. Each domain score was calculated by summing responses from the relevant items and dividing by the total number of items in the domain. Scores above the midpoint (2.0) indicated a stigmatizing attitude, with higher scores indicating more severe public stigma.

Statistical Analyses

Statistical analyses were conducted with SPSS, version 20.0. The Kolmogorov-Smirnov test was used to test for normality of noncategorical variables, and Wilcoxon signed-rank tests were used to examine differences in scores between pairs of vignettes. Kruskal-Wallis or Mann-Whitney tests examined differences in scores between demographic variables.

Results

Demographic Characteristics

As shown in Table 1, 204 participants (154 from the general public and 50 health care professionals) completed the questionnaires. The mean age of the 204 participants was 27.3. Seventy percent were female, and 64% had undergraduate or postgraduate degrees. Most participants did not have relatives or close friends who had been hospitalized in a psychiatric unit. However, about half (43%) had worked or volunteered in mental health services.

Domain Scores Across Vignettes

As shown in Table 2, total stigma scores were highest for schizophrenia, followed by APS, depression, and psychosis-like experiences. For both schizophrenia and psychosis-like experiences, total stigma scores and all domain scores differed significantly (p<.001) from scores for the other vignettes. For APS and depression, only the domain score for treatment carryover differed significantly.

For APS and depression, the order of domains as ranked by score was similar; the domain with the highest score for both vignettes was disclosure spillover, followed by perception of dangerousness, and treatment carryover. For APS, the two domains with the next-highest scores were social distance and traditional prejudice, followed by negative affect and exclusionary sentiments. In contrast, for depression, the two domains with the next-highest scores were traditional prejudice and social distance, also followed by negative affect and exclusionary sentiments. However, there was no significant difference between domain rankings for depression. For schizophrenia, domain rankings were as follows (from highest to lowest score): disclosure spillover, perception of dangerousness, treatment carryover, social distance, negative affect, traditional prejudice, and exclusionary sentiments. Significant differences with other vignettes were noted for social distance (Z=−2.00, p<.05) and negative affect (Z=−1.97, p<.05). For psychosis-like experiences, domain rankings were as follows: disclosure spillover, treatment carryover, traditional prejudice, social distance, dangerousness, exclusionary sentiments. Significant differences with other vignettes were noted for treatment carryover (Z=−2.09, p<.05), and exclusionary sentiments (Z=−2.11, p<.05).

Total Scores Across Vignettes by Characteristic

Table 3 presents total public stigma scores for each vignette by demographic and other characteristics. For the APS vignette, total scores of participants from the general public were higher than scores of health care professionals (Z=−3.0, p<.01); the scores for these two groups did not differ significantly for any other vignette. For the APS vignette, some domain scores (data not shown) were also significantly higher for the public group than for the professional group: social distance (Z=−2.86, p<.01), negative affect (Z=−3.98, p<.001), and perceptions of dangerousness (Z=−2.39, p<.05). No significant differences between rankings were found by gender and age for any vignette.

Significant differences in total stigma scores were found by education level for both the APS and the schizophrenia vignettes. For the APS vignette, participants who had a high school diploma had significantly higher scores than participants in the other education-level groups (χ²=12.8, df=4, p<.05). For the APS vignette, scores in two domains (data not shown) were also significantly higher for those with a high school diploma than for those in the other education-level groups: traditional prejudice (χ²=11.7, df=4, p<.05) and negative affect (χ²=13.0, df=4, p<.05). For the schizophrenia vignette, participants without a high school diploma (secondary level) had significantly higher scores than those in the other education-level groups on one domain: treatment carryover (χ²=11.1, df=4, p<.05).

For all vignettes, total stigma scores of participants who reported working or volunteering in mental health services were significantly lower than total scores of participants who reported no such experiences (Table 3). For the APS vignette, not only did the total stigma score differ between these groups (χ²=24.1, df=2, p<.001), but the scores on five domains (data not shown) also differed: social distance (χ²=25.7, df=2, p<.001), traditional prejudice (χ²=10.2, df=2, p<.01), negative affect (χ²=26.0, df=2, p<.001), perception of dangerousness (χ²=13.2, df=2, p<.001), and treatment carryover (χ²=8.6, df=2, p<.01). For the schizophrenia vignette, scores between the general public and health care professionals differed for two domains: negative affect (χ²=8.0, df=2, p<.05) and treatment carryover (χ²=9.8, df=2, p<.01). For the depression vignette, scores between the two groups differed only for the domain of treatment carryover (χ²=8.9, df=2, p<.05). For the psychosis-like experiences vignette, scores between the two groups differed for two domains: exclusionary sentiments (χ²=8.5, df=2, p<.05) and negative affect (χ²=8.6, df=2, p<.01).

Finally, for the APS vignette, participants who reported encountering someone in public who appeared to be mentally ill either often or sometimes had higher scores on two domains than those who reported almost never having such encounters (data not shown): exclusionary sentiments (χ²=1.0, df=3, p<.05) and negative affect (χ²=15.3, df=3, p<.01).

Discussion

In this cross-sectional study involving 204 participants, we found that the stigma scores of the general public were highest for schizophrenia, followed by APS, depression, and psychosis-like experiences. Of note, stigma scores indicated that APS and depression were perceived similarly by study participants; however, significantly higher scores for APS on the domain of treatment carryover indicated that participants believed that being known to have received treatment for APS would have more lasting consequences than treatment for depression. Demographic and other characteristics appeared to have affected stigma scores for the four mental health conditions, with the largest effects seen for APS. Characteristics that affected stigma included participants’ education level, the frequency with which they encountered in public someone who appeared to be mentally ill, whether or not they were a health care professional, and whether they worked or volunteered in mental health services.

Studying public stigma associated with various mental health conditions is important because stigma can affect help-seeking behavior and recovery. Public stigma associated with APS was found to be weaker than that associated with schizophrenia, whereas stigma associated with APS and depression was similar. This finding suggests that substantial public stigma is associated with APS; being known to have received treatment for APS was perceived as having lasting consequences. The findings also suggest potential stigma reduction strategies; for example, the public should be informed about the high remission rate among individuals who experience psychotic symptoms and the potential for complete recovery. A positive finding is that even though symptoms of APS and schizophrenia have similar presentations, stigma scores were lower for APS. This finding may be related to uncertainty about whether all individuals with APS transition to a full-blown psychotic disorder.

Ranking by score on stigma domains for schizophrenia differed more than for the other conditions. For schizophrenia, higher scores were given to “immediate emotion-focused” domains, such as perceptions of dangerousness, negative affect, and social distance, and scores for “higher-order social values,” such as traditional prejudice, were lower (19,21). This finding may result from differences in how the public perceives the role of biopsychosocial factors in these illnesses. The public may view biopsychosocial factors as playing a larger role in APS and depression, compared with schizophrenia (22). In addition, the public may view the individual affected by APS or depression as being more responsible for having the illness, as reflected in the scores for traditional prejudice and negative affect.

This study had several limitations. First, the study did not assess self-stigma. Second, there was no qualitative investigation of participants’ stigma perceptions, which may have provided additional insight into beliefs held by the general public. Third, the concept of APS is relatively new, and we did not assess public knowledge about APS. Although we provided a working definition of APS for participants, their stigma ratings may also have depended on their previous knowledge or experiences. Fourth, the participants may not have been representative of the larger population. Fifth, although the vignettes were reviewed by local experienced psychiatrists for face validity before use, the validity had not been studied in Chinese culture. Sixth, the 4-point scale may not have been able to distinguish between APS and depression groups. Finally, our study was limited to the investigation of public stigma in the Chinese culture, and generalization to Western cultures may not be feasible. Future studies of APS in countries with different beliefs and cultures are warranted.

Conclusions

This study not only expands literature on public stigma associated with mental illnesses but also contributes to future considerations about whether APS should be a clinical diagnostic category. Understanding how the public perceives APS can inform future research and development of clinical services. Stigma reduction programs should consider ways to increase the public’s contact with persons with mental illness. To alter negative views of mental illness, such programs should provide accurate information about the dangerousness of persons with mental illness and about positive treatment outcomes.