Medical Student Beliefs and Attitudes Toward Mental Illness Across Five Nations Elina A. Stefanovics, PhD,*† Robert A. Rosenheck, MD,*† Hongo He, MD, PhD,‡ Angela Ofori-Atta, PhD,§ Maria Cavalcanti, PhD,|| and Catherine Chiles, MD*† Abstract: Negative attitudes toward people with mental illness are a widespread concern and may vary across countries. This study used a 36-item questionnaire to compare attitudes toward people with mental illness and beliefs about the causes of mental illness among medical students from the United States, Brazil, Ghana, Nigeria, and China (N = 1131). Exploratory factor analysis identified the underlying factor structure of the questionnaire, and analysis of covariance was then used to compare factors representing four nonstigmatized attitudes across students from the five countries. US Medical students scored highest on all four factors, followed by those from Brazil. Nigerian and Ghanaian students scored lowest on nonsupernatural etiology of mental illness, and Chinese students showed the lowest score on personal social acceptance and public policy accep- tance of people with mental illness. Differences in medical student attitudes be- tween these five countries suggest underlying sociocultural differences in attitudes with the more stigmatized attitudes in developing countries. Key Words: Attitudes to mental illness, medical students, cross-cultural research (J Nerv Ment Dis 2016;204: 909–915) M ental illness and substance use disorders have been identified as a leading cause of years lost to disability worldwide (Ustün et al., 2004; Whiteford et al., 2013), and organizations such as the World Health Organization (WHO), the World Psychiatric Association, and the Association for Social Psychiatry have all identified stigma toward people with mental illness as a major public health challenge (WHO, 2001). The term “stigma” was originally used to refer to a brand or scar burned or cut into the body to identify slaves and criminals (Clausen, 1981). More recent conceptions of stigma reflect four social-cognitive processes: a) signals, such as mental illness labels, symptoms, and so- cial skills deficits; b) stereotypes, which are knowledge structures or be- liefs about people with mental illness; c) prejudiced attitudes, which reflect an evaluative component and personal judgment; and d) discrim- inatory behaviors (Corrigan, 2004). Beliefs, perceptions, stereotypes, prejudiced attitudes, and be- haviors toward people with mental illness may be strongly influenced by social environment and cultural context, but little empirical research has directly evaluated this hypothesis. Sociocultural norms can be un- derstood as sets of judgments, assumptions, and opinions that shape so- cial stereotypes that individuals absorb as they are raised in a particular society (Helman, 2007). These stereotypes are considered “social” be- cause they represent collective agreement upon notions of groups of people. They are very “efficient” because a person can quickly generate impressions and expectations of individuals who belong to a stereotyped group (Wyer and Srull, 1994). In contrast to stereotypes, which are es- tablished beliefs, prejudicial attitudes involve an emotional response to a stigmatized group (Eagly and Chaiken, 1993). These may lead to be- havioral reactions, which include hostile behavior fear that, in turn, leads to avoidance (Weiner, 1995). Cultural norms also form the conventional judgments of what behaviors are considered normal; which are considered abnormal, un- usual, or unexpected; and which may be attributable to deviance such as witchcraft or mental illness. For example, it might be accepted and seem normal in certain Middle Eastern cultures to experience visions and hear “voices, ” whereas in most Western cultures, such occurrences might be categorized as hallucinations and indicate specific mental ill- nesses (Al-Issa, 1995). There are several specific culturally shaped influences that im- pact beliefs about mental and mental health–related stigma. These in- clude culture-specific beliefs regarding the etiology of mental illness and culture-specific stigmatizing beliefs about the dangers of mental ill- ness (Angermeyer et al., 2004; Littlewood et al., 2007). In one cross- cultural survey of people in Australia and Japan, Australians were more likely to believe that infection, allergy, or genetics are causes of mental illness, whereas the Japanese tended to believe in “weakness of charac- ter” and were less optimistic about the potential for recovery (Nakane et al., 2005). Similarly, a survey conducted in Turkey found that more than 60% of the rural population believed that “weakness of personal- ity” is a cause of schizophrenia (Taskin et al., 2003). One third of a large community sample of Nigerians endorsed evil spirits as a cause of men- tal illness, and 96% of the sample considered people with mental illness to be dangerous (Gureje et al., 2005). Most Malaysian patients with be- havioral symptoms attributed their problems to supernatural agents and more specifically witchcraft and possession by evil spirits (Razali et al., 1996). Although in some non-Western cultures, supernatural phenom- ena, such as witchcraft and possession by evil spirits, are seen as impor- tant and causes of mental disorders, this is uncommon in the West (Angermeyer and Matschinger, 1999b). In the General Social Survey, administered to a nationwide representative sample of adults living in the United States, stressful circumstances were the most commonly en- dorsed cause of five possible mental health conditions (alcohol depen- dence, depression, schizophrenia, drug dependence, and “troubled person” with subclinical problems and worries) (Link et al., 1999). A representative survey of lay concepts of schizophrenia and depression carried out in Germany revealed that psychosocial stress was most fre- quently seen as etiologically relevant (Angermeyer and Matschinger, 1999a). Surveys have consistently demonstrated that stigmatizing atti- tudes and beliefs toward people with mental illness are also present among physicians and are shared by other mental health professionals (Chambers et al., 2010; Crisp et al., 2000; Dietrich et al., 2004; Markström et al., 2009; Mukherjee et al., 2002; Nordt et al., 2006). The attitudes of medical students toward people with mental ill- ness may be of particular importance, as these students represent the fu- ture leaders of their profession and are likely to become thought leaders in their societies. Attitudinal studies that specifically evaluated stigma among medical students have found negative opinions toward people with mental illness that are similar to those observed in the general pop- ulation (Furnham and Murao, 2000; Mas and Hatim, 2002). A study *Yale University School of Medicine (YUSM), New Haven; †Veterans Affairs (VA) New England Mental Illness Research and Education Clinical Center (MIRECC), West Haven, CT; ‡Guangzhou Psychiatric and Brain Hospital of Guangzhou Medical University, China; §Medical School College of Health Sciences, Univer- sity of Ghana, Accra, Ghana; and ||Federal University of Rio de Janeiro, Brazil. Send reprint requests to Elina A. Stefanovics, PhD, VA New England Mental Illness, Research, Education and Clinical Center, VA Connecticut Healthcare System (116A-4), 950 Campbell Avenue, Building 36, West Haven, CT 06516. E‐mail: elina.stefanovics@yale.edu. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/16/20412–0909 DOI: 10.1097/NMD.0000000000000610 ORIGINAL ARTICLE The Journal of Nervous and Mental Disease • Volume 204, Number 12, December 2016 www.jonmd.com 909 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.