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Stigmatization of 'psychiatric label' by medical and non-medical students


Sanja Totic, Dragan Stojiljkovic, Zorana Pavlovic, Nenad Zaric, Boris Zarkovic, Ljubica Malic, Marina Mihaljevic, Miroslava Jasovic-Gasic and Nadja P. Maric Int J Soc Psychiatry 2012 58: 455 originally published online 30 June 2011 DOI: 10.1177/0020764011408542 The online version of this article can be found at: http://isp.sagepub.com/content/58/5/455

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ISP58510.1177/0020764011408542Mari et al.International Journal of Social Psychiatry

E CAMDEN SCHIZOPH

Article

Stigmatization of psychiatric label by medical and non-medical students


Sanja Totic,1,2 Dragan Stojiljkovic 2 Zorana Pavlovic,1 , 2 Boris Zarkovic,2 Ljubica Malic,2 Marina Mihaljevic,1 Nenad Zaric, Miroslava Jaovic -Gaic 1,2 and Nadja P. Maric 1,2

International Journal of Social Psychiatry 58(5) 455462 The Author(s) 2011 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764011408542 isp.sagepub.com

Abstract Backround: Stigmatization of psychiatric patients is present both in the general population and among healthcare professionals. Aim: To determine the attitudes and behaviour of medical students towards a person who goes to a psychiatrist, before and after psychiatric rotation, and to compare those attitudes between medical and non-medical students. Methods: The study included 525 medical students (second and sixth year of studies) and 154 students of law. The study instrument was a three-part self-reported questionnaire (socio-demographic data, Rosenberg Self-Esteem Scale and a vignette depicting a young, mentally healthy person). The experimental intervention consisted of ascribing a psychiatric label to only one set of vignettes. All the vignettes (with or without the psychiatric label) were followed by 14 statements addressing the acceptance of a person described by vignette, as judged by social distance (four-point Likert scale). Results: Higher tendency to stigmatize was found in medical students in the final year, after psychiatric rotation (ZU = 3.12, p = .002), particularly in a closer relationship (ZU = 2.67, p = .007) between a student and a hypothetical person who goes to a psychiatrist. The non-medical students had a similar tendency to stigmatize as medical students before psychiatric rotation (ZU = 0.03, p = .975). Neither gender, nor the size of students place of origin or average academic mark was associated with the tendency to stigmatize in our sample. However, students elf-esteem was lower in those with a tendency to stigmatize more in a distant relationship ( = 0.157, p = .005). Conclusions: Psychiatric education can either reinforce stigmatization or reduce it. Therefore, detailed analyses of educational domains that reinforce stigma will be the starting point for anti-stigma action. Keywords stigma, medical students, medical education, discrimination, psychiatry

Introduction
Stigmatization is a global phenomenon of social labelling, stamping a person in order to discriminate, degrade or classify them in a socially undesirable category of being harmful and dangerous. Stigma in relation to people with mental illness can be understood as a combination of problems of knowledge (ignorance), attitudes (prejudice) and behaviour (discrimination) (Thornicroft, Brohan, Kassam, & Lewis-Holmes, 2008). Stigmatization of psychiatric patients, which is widely present over the world, affects treatment and socialization of psychiatric patients and could be considered as an environmental risk factor for mental illnesses (van Zelst, 2009). It is this phenomenon that is responsible for the fact that a great number of people with psychiatric disorders do not even try to ask for medical help. The very process of stigmatization could be considered from two points of view: personal feeling of being stigmatized, i.e. self-stigma (feelings like anger, depression, fear, anxiety, guilt, embarrassment (Dinos, Stevens, Serfaty, Weich, & King, 2004)), or imputing a label to other person, i.e. public stigma (stereotypes, prejudices and discrimination (Corrigan & Watson, 2002). The literature suggests that being stigmatized is associated with
1Clinic 2School

of Psychiatry, Clinical Centre Serbia, Belgrade, Serbia of Medicine, University of Belgrade, Serbia

Corresponding author: Nadja P. Maric, Assoc. Prof., psychiatrist, Clinic for Psychiatry CCS, Belgrade, Serbia, Pasterova 2 Email: nadjamaric@yahoo.com

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456 low self-esteem (Link, Struening, Neese-Todd, Asmussen, & Phelan, 2001; Verhaeghe, Braceke, & Bruynooghe 2008), one important personality dimension that reflects a persons overall evaluation or appraisal of his or her own worth, but little is known about the self-esteem of stigmatizers. Interestingly, according to Crandall and Cohen (1994), possible candidates for individual differences that would lead to a greater or lesser rejection of a stigmatized one include low self-esteem, alienation, authoritarianism and social-cultural ideology. Although some literature suggests that public stigma is lower among younger people and individuals with higher educational levels (Angermeyer, Matschinger, & Corrigan, 2004; Arvaniti, Samakouri, Kalamara, Bochtsou, Bikos, & Livaditis, 2009), strong negative emotional reactions towards people with mental illness have been found in secondary schoolchildren from different world regions (Ronzoni, Dogra, Omigbodun, Bella, & Atilola, 2009; Rose, Thornicroft, Pinfold, & Kassam, 2007) and in medical doctors and medical students (Ogunsemi, Odusan, & Olatawura 2008; Schulze, 2007). The level of stigmatization by medical students is uneven regarding different disorders, such as schizophrenia, depression, obsessivecompulsive disorder (OCD) and self-harm (Fernando, Deane, & McLeod, 2010; Law, Rostill-Brookes, & Goodman, 2009; Simonds & Thorpe, 2003) but sometimes it seems that future doctors stigmatize psychiatric label itself. When Ogunsemi et al. (2008) evaluated the effect of psychiatric label attached to an apparently normal person on the attitude of final year medical students, it resulted in students wanting to maintain a significant distance from the person labelled mentally ill. However, negative attitudes may be modified by the level of education and direct contact with mentally ill people, as has been shown in two studies from our region that focused on Belgrade adolescents (Pejovi-Milovancevi, Leci-Tosevski, Tenjovi, Popovi-Deusi, & DraganiGaji, 2009) and Greek students and professionals (Arvaniti et al., 2009). Chung, Chen, and Liu (2001) found that Chinese medical and dental students were more accepting towards a person labelled as mentally ill when compared with social science and engineering students. The present study was carried out at the School of Medicine and the School of Law, University of Belgrade, using a hypothetical vignette of an apparently healthy young person and experimentally manipulating attributions of psychiatric label. The aim of this study was (1) to record the attitudes and behaviour of medical students towards a person with a psychiatric label before and after the psychiatric rotation, (b) to compare the attitudes and behaviour between medical and non-medical students, and (c) to investigate associations between the level of stigmatization and students characteristics (demography, academic achievement and self-esteem).

International Journal of Social Psychiatry 58(5) Based on the results of previous studies, we hypothesized that participants who had more knowledge about mental illness would have more positive attitudes and behaviour. Previous similar research has never been conducted in former Yugoslavia and Serbia, and there is no data to show stigmatization on the national level.

Methods
The study was conducted in accordance with the provisions of The Helsinki Declaration and independent consent was obtained from the School of Medicine (Department for Physiology and Forensic Medicine) and the School of Law (Department for Tax Law), University of Belgrade.

Research setting
At the School of Medicine, University Belgrade, undergraduate education in psychiatry is based on the traditional curriculum over a 30-week course in the fourth year (a single course on clinical education), where students participate in centralized sessions for theoretical education (30 hours) alternating with smaller group sessions at clinical sites (60 hours). Students are introduced to the mental status exam and psychiatric interviewing as well as the diagnostic features, epidemiology, clinical course, treatment and neurobiology of the core psychiatric disorders. Clerkship assignments are available in inpatient units and partial hospital programmes and students mostly rotate. This means that student contact is with different patients in terms of either diagnosis or phase of the illness course. All clinical psychiatric experience is gained in the fourth year. Second year students have no school-related contact with psychiatry, while all sixth year students complete the rotation and pass the exam in psychiatry. In our previous studies of attitudes towards psychiatry as a career choice, fifth year students had lower attitude scores regarding psychiatry in comparison to their younger colleagues, when averaged on their background and attitudes towards other residencies: positive attitude was evident in 15% sophomores and 16% seniors, while 25% and 47%, respectively, stated they would never consider psychiatry as a possible residency (Mari, Stojiljkovi, Mileki, Milanov, Stevanovic, & Jaovi-Gai, 2009; Mari, Stojiljkovi, Mileki, Milanov, Bijelic, & Jaovi-Gai, 2011). This decrease of interest was due to an increase in the number of students who showed a negative attitude towards psychiatry. However, although our data showed a decrease in affinity towards psychiatry during studies, the level of interested students is still one of the highest reported in recent literature. In the past couple of years, about 4.4% of total medical school graduates applied for a residency in psychiatry (data

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Totic et al. for year 2006, Postgraduate Studies Department at School of Medicine, University of Belgrade). Finally, the ratio of psychiatrists in Serbia was about 10 per 100,000 population during the last decade. Psychiatric services in Serbia have been mostly hospital centred. The Serbian National Committee for Mental Health was established in 2003 and de-stigmatization of persons with psychiatric disorders became part of the National Strategy for Development of Mental Helath Care in 2007 (Pejovi-Milovancevi et al., 2009). Law students do not learn specifically about psychiatry, i.e. how to recognize mental symptoms or disorders. There is no particular subject such as Insanity defence or similar, although they do have some information on how to protect the rights of persons with psychiatric disorders. The draft of the Mental Health Law (as a part of the National Strategy for Development of Mental Health Care) is still beyond its official application. Both schools comply with the conditions of the Bologna Declaration, the process to create a unique European higher education area by making academic degree and quality assurance standards more comparable and compatible throughout Europe.

457 previous studies (Chung et al., 2001; Ogunsemi et al., 2008). Two statements from the original questionnaire (Ogunsemi et al., 2008) were omitted as considered culturally unsuitable.

Vignette
The text in the vignette was as follows:
NN is mainly considered to be a cheerful and happy person. Surrounded by close people, NN easily shows own feelings and opinions, while in the group of people NN does not know, NN turns to a tense person. NN is generally in good terms with cousins, as well as with the majority of other people. We could say that NN leads a normal life for his/her own age and that NN balance well with social life (making friends) and studying.

Statements
Using the four-point Likert scale (1 = agree completely, 2 = agree, 3 = disagree, 4 = disagree completely), the students determined how much they were in agreement with the statements referring to the person featured in the vignette. Experimental intervention in the present study was to impute a psychiatric label to the featured person by the statement NN goes to a psychiatrist at the end of the vignette text. There were two versions of the questionnaire: with and without the psychiatric label. Each group of students (cluster) was given one version of the questionnaire so that they would not see the difference between the vignettes; the labelled vignette was distributed to 49.5% of the second year students and 47.7% of the final year students from the School of Medicine and to 49.4% of the final year students from the School of Law). In our pilot study, we showed that the questionnaire was applicable to the Serbian population, the response rate was high and the internal consistency was good (Munjiza, Stojiljkovi, Mileki, Latkovi, Jaovi-Gai, & Mari, 2010; Stojiljkovi, Music, Munjiza, JaoviGai, Totic-Poznanovic, & Mari, 2009). Moreover, our data analysis yielded a two-factor structure of stigmatizing statements: stigma imputed in a distant or close relationship. Imputing stigma in the distant relationship means discrimination and underestimation of a person at the level of social conscience of an individual (items 1, 2, 4, 5, 7, 9, see Table 1). Stigma in the close relationship refers to the contact that requires a higher level of intimacy between the subject and the object of stigmatization (items 3, 8, 1014, see Table 1). The item number 6 (It would be uncomfortable to me to talk about my private problems to NN) performed poorly in terms of internal consistency with other items and was thus omitted from subsequent analyses.

Participants and procedures


The study included students from the University of Belgrade who in 2008 entered the second and sixth year at the School of Medicine and students who in 2009 entered the fourth year at the School of Law. Testing was performed by some of the authors (NZ, BZ, LM and MM who were students at this time) within the first semester, during the regular teaching (classes) in the above-mentioned departments with the permission of teaching staff. All the students who attended the lectures during one week (survey period) were invited to participate. Participants were not familiar with the fact that psychiatrists would supervise the questionnaire. The study was designed as a randomized cluster experiment. The study instrument was a three-part self-reported questionnaire. The first part included socio-demographic data (gender, date of birth, secondary school finished, population of place of residence), as well as average mark within studies. The second part was the Rosenberg SelfEsteem Scale (Rosenberg, 1979), with 10 statements evaluated on a four-point Likert scale. The third part of the questionnaire was a vignette depicting a young, mentally healthy, but shy person, as well as 14 statements (attitudes and behaviour) addressing the acceptance of a person described by a vignette as judged by social distance (social stigmatization), to be evaluated on a four-point Likert scale. A higher social distance score indicated a stronger rejection of the given subject. The case description and the questionnaire were modified versions of those used in

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Table 1. Factor structure of stigmatizing statements Stigmatization In distant relationship I would feel unpleasant if I sat next to NN in city transport. It would upset me to buy something from NN in a shop. It would disturb me to meet NN at a meeting (birthday party, celebration). I would refuse to play cards with NN. I would complain if NN became my neighbour. I would feel uncomfortable to work with NN in the same company.

International Journal of Social Psychiatry 58(5)

In close relationship I would find it unpleasant to rent NN a flat. It would be disturbing to have NN for my hairdresser. I would be uncomfortable to share an office with NN. I would oppose the marriage of my sister/brother to NN. Friendship with NN would psychologically press me. Friendship with NN would cause physical fatigue in me. Being friends with NN would negatively affect my mental health.

Statistical analysis
The data were statistically processed using the software package PASW Statistics 18 (SPSS Inc. Chicago, IL). Continuous variables were described using the arithmetic mean (M) and standard deviation (SD) statistics. The MannWhitneys rank sum test (U), Pearsons chi-square test of independence (2) and Spearmans correlation of ranks (rho, ) . The two-factor structure of stigmatizing statements was confirmed using principal components analysis with promax oblique factor rotation.

Law. The socio-demographic characteristics of the students are shown in Tables 2 and 3.

Stigmatization of psychiatric label


The second year medical students showed similar levels of social distance to the labelled and unlabelled person from the vignette (ZU = 0.53, p = .600). They imputed statistically significantly less stigma in a distant relationship (ZU = 2.46, p = .014) with the labelled person, and the same level of stigmatization in close interactions (ZU = 1.25, p = .210) with the unlabelled person. The sixth year students of medicine showed a higher distance to the labelled than to unlabelled person from the vignette (ZU = 3.12, p = .002). The levels of stigmatization in the distant relationship were not significantly different (ZU = 0.39, p = .695), but the level of stigmatization in a closer relationship with the labelled person was significantly higher (ZU = 4.94, p < .001).

Results Description of the samples


A total of 679 students correctly filled in questionnaires; 525 students were from the School of Medicine (229 second year and 296 sixth year), while 154 were from the School of

Table 2. Socio-demographic characteristics of the students by the school and the year of studies School of Medicine Second year (n = 229) n Gender Male 74 Female 153 Place of origin (number of inhabitants) >100,000 90 <100,000 133 M Age Average academic mark Self-esteem score 20.25 7.90 20.96 % 32.6 67.4 40.4 59.6 SD 0.68 0.94 4.45 School of Medicine Sixth year (n = 296) n 92 204 125 171 M 25.21 8.40 21.65 % 31.1 68.9 42.2 57.8 SD 1.54 0.72 4.52 School of Law Fourth year (n = 154) n 54 100 77 77 M 22.71 7.86 20.78 % 35.1 64.9 50.0 50.0 SD 1.04 0.80 4.15 Total (N = 679) n 220 457 292 381 M 22.98 8.11 21.22 % 32.5 67.5 43.4 56.6 SD 2.48 0.85 4.43

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Totic et al.
Table 3. Socio-demographic characteristics of all students by vignette distribution Non-labelled vignette (n = 345) n Gender Male Female Place of origin (number of inhabitants) >100,000 <100,000 98 253 149 200 M Age Average academic mark Self-esteem score 22.91 8.24 21.25 % 44.5 55.4 51.0 52.5 SD 2.44 0.83 4.35 Labelled vignette (n = 334) n 122 204 143 181 M 23.05 7.96 21.17

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% 55.5 44.6 49.0 47.5 SD 2.51 0.85 4.50

The students of law imputed similar levels of stigma to the labelled and unlabelled person from the vignette in terms of the total stigma score (ZU = 0.03, p = .975), distant (ZU = 0.24, p = .808) and close (ZU = 0.16, p = .873) relationship.

Stigmatization in medical students before and after psychiatric rotation


The sixth year medical students had a statistically significantly higher tendency to stigmatize the labelled person in comparison to the second year medical students (ZU = 2.04, p = .042). The difference was also statistically significant for close relationship (ZU = 2.67, p = .007), but not for distant relationship (ZU = 0.59, p = .554) with the labelled person. No statistically significant differences were found between second and sixth year medical students in terms of stigmatization of the unlabelled person, neither in total stigmatization score (ZU = 1.54, p = .122), nor in distant (ZU = 1.72, p = .085) and close (ZU = 0.98, p = .326) relation with NN.

terms of total stigmatization score towards the labelled person (ZU = 1.21, p = .227) and the distant relations domain of stigmatization (ZU = 0.56, p = .576). The sixth year medical students reported a higher level of stigmatization in close interactions with the labelled person when compared to the students of law (ZU = 2.79, p = .005). The attitudes of these two groups did not differ towards the unlabelled person (total stigma score: ZU = 1.22, p = .223, distant relationship: ZU = 0.64, p = .520, close relationship: ZU = 1.58, p = .113).

Socio-demographic characteristics of students and stigmatization


The vignettes with or without a label were almost equally distributed in relation to the socio-demografic characteristics of the sample (Table 3). The data showed that male and female students had a similar tendency to stigmatize the psychiatric label (ZU = 0.71, p = .479). The differences were not statistically significant in close (ZU = 0.64, p = .520) or in distant (ZU = 1.15, p = .252) relationships. The students coming from larger (> 100,000 inhabitants) and smaller (< 100,000) towns had a similar tendency to stigmatize the psychiatric label (ZU = 1.33, p = .183). The differences were not statistically significant in distant (ZU = 1.54, p = .123) or close (ZU = 1.02, p = .306) relationships.

Stigmatization in medical and non-medical students


The second year students of medicine were not statistically significantly different from the students of law in terms of total stigmatization (ZU = 0.12, p = .902), or distant (ZU = 0.99, p = .324) and close (ZU = 0.76, p = .445) relationship with the labelled person. Similarly, the attitudes of these two groups did not differ towards the unlabelled person (total stigma score: ZU = 0.46, p = .643, distant relationship: ZU = 1.06, p = .291, close relationship: ZU = 0.49, p = .633). No statistically significant differences were found between the sixth year medical students and law students in

Average academic mark and stigmatization


Average academic mark was not statistically significantly correlated to stigmatization of the psychiatric label ( = 0.045, p = .430). Neither the distant ( = 0.039, p = .448) nor close ( = 0.087, p = .126) domain of social interactions with NN was correlated with an average academic mark.

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International Journal of Social Psychiatry 58(5)

Figure 1. Stigmatizing statements in labelled and non-labelled vignette by the three groups of students

Self-esteem and stigmatization


Self-esteem measured by the Rosenberg Self-Esteem Scale (Rosenberg, 1979) was not statistically significantly correlated with the total score of stigmatization of the labelled person ( = 0.019, p = .736). However, self-esteem was negatively correlated with stigmatization in a distant relationship ( = 0.157, p = .005) and positively correlated with stigmatization in a close relationship ( = 0.127, p = .023) with NN.

Discussion
Medical education can both aggravate and reduce social distance towards a person who goes to a psychiatrist. The results of our study show that medical students stigmatize a person with a psychiatric label more in their final year, after psychiatric rotation. The non-medical students had a similar tendency to stigmatize as the medical students before psychiatric rotation. A higher level of stigmatization was evident in relations that require a closer relationship between the student and the hypothetical person who sees a psychiatrist. The data from this study are inconsistent with previously published data. We did not confirm that medical students stigmatize less that non-medical, as shown by Chung et al. (2001), nor that final year students improve their attitudes towards the mentally ill (Ay, Save, & Fidanoglu, 2006).

Neither gender, size of students place of origin nor average academic mark was associated with the tendency to stigmatize in our sample. However, a negative attitude that resulted in maintaining a significant distance from the labelled person was associated with students self-esteem: students with lower self-esteem were more prone to input stigma into distant relationship, while those whose selfesteem was higher stigmatized in closer relationships. From the literature, we know that self-esteem is an important factor for the evaluation of self-stigma (Link et al., 2001; Verhaeghe et al., 2008), but little is known about the self-esteem of stigmatizers. Crandall and Cohen (1994) evaluated personality of stigmatizer and concluded that two factors predicted rejection: (1) a cynical world view, characterized by alienation, loneliness and little faith in people and (2) conventionalism, characterized by authoritarianism and a belief in a just world. However, the authors did not find that self-esteem predicted the rejection. Our findings show that lower self-esteem, associated with the feeling of low competency and dependency on other peoples approval, was associated with rejection in relations that include the presence of others (meeting a labelled person at a party or celebration, to work with him/her, etc.). Our method used a vignette of an apparently normal person labelled as goes to a psychiatrist, thus the results can be interpreted not in relation to the particular disorder and its treatment, but to psychiatry as a discipline. The findings

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Totic et al. of the present study provide support for an earlier report by our group on the attitudes of students towards psychiatry as a career at the School of Medicine, Belgrade (Mari et al., 2009; Mari et al., in press). In the sample of 105 sophomore and 75 senior students, we found a decrease in an interest in psychiatry after students had completed the psychiatric clerkship. The observed change was not due to a decrease in the number of interested students over the course of medical education, but to an increase in the number of students who show a negative attitude towards psychiatry (typical answer: I would never choose psychiatry for my future residency), view psychiatry unfavourably, and lack confidence and respect for both psychiatrists and the field. The precise origin of these unfavourable changes in students attitudes towards psychiatry and a patient who sees a psychiatrist is not known, but it is possible that contact with patients with mental illness at the severe end of the spectrum may contribute, as suggested by Fernando et al. (2010). Contact with a recovered patient could be effective in reducing stigma (Thornicroft et al., 2008), but the examined students had classes that too frequently exposed them to interactions with severe and hospitalized patients and the training course was too short to observe the clinical course that led to recovery. Also, if education overestimated the factors of inheritance, but underestimated the nature and nurture interactions, epigenetic dynamics and humanistic approach that relies on individual potential more than limitations due to symptoms, pessimistic attitudes towards the effectiveness of treatment might be formed or sustained. Even if appropriate educational intervention and experience are gained, the question arises about how long their effects will sustain. In a one-year follow-up study in the UK (Baxter, Singh, Standen, & Duggan, 2001), it was shown that a positive change in medical students attitudes towards psychiatry, psychiatrists and mental illness after their fourth year psychiatric training was transient and decayed over the final year. Medical students experience significant distress from adjustment to the medical school environment, perceived ethical and professional dilemmas, first-time exposure to death and human suffering, personal life events and educational debt (Dyrbye, Thomas, & Shanafelt, 2005). The data obtained by several authors (Patenaude, Niyonsenga, & Fafard, 2003; Woloschuk, Harasym, & Temple, 2004) showed a decline in empathy and an increase in cynicism during the course of medical school. The decline in empathy could be related to aspects of student distress and quality of life rather than progression through the training curriculum alone (Thomas et al., 2007). Knowledge of to what degree stigma exists in medical training is important as it leads to an understanding of why psychiatry has low recruitment and how psychiatric patients may be treated by doctors. Stigma is inherent in the social structures that make up society (Corrigan & Watson, 2002). The methods of

461 supplementary educational programmes in producing enduring change in medical students attitudes towards psychiatry, patients and mental illness should be associated with interventions on a global, national level. In a way, our research could be considered as a baseline assessment that facilitates the evaluation of such global interventions at the level of medical school.

Limitations
Finally, some limitations of the study should be mentioned. Our method did not explore whether students had previous personal (not school-related) experience with anyone who goes to a psychiatrist. Although we are aware that a certain experience can influence social distance in participants, we intentionally avoided any question that could influence students attitudes towards an unlabelled vignette. The generalizability of the findings here cannot be assumed due to the use of only two university schools, and further studies are needed to analyse a randomly sampled Belgrade University student population. However, only medical students have a six-year undergraduate programme and other students cannot be matched ideally. Another limitation is using an unpaired sample of medical students; this problem could be overcome by performing a longitudinal follow-up study. We nevertheless believe that these restrictions do not reduce the value and importance of our study.

Conclusion
Our study evaluated the tendency to stigmatize a hypothetical person who goes to a psychiatrist and showed that it was higher in the final year medical students in comparison to younger colleagues and students of law. Since stigmatization arises after a psychiatric rotation, this finding might be associated with experiences gained through education and could reflect attitudes and behaviour not only towards the patient, but to psychiatry as a discipline. Psychiatric education can either reinforce stigmatization or reduce it. Therefore, detailed analyses of educational domains that reinforce stigma are the starting point of any anti-stigma action, in parallel with a national multisectoral programme of action to promote the social inclusion of people with mental illness. References
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