Anti-stigma training and positive changes in mental health illness stigma outcomes in medical students in ten countries: A mediation analysis on pathways via empathy development and anxiety reduction

Purpose: Studies of mental illness stigma reduction interventions have been criticised for failing to evaluate behavioural

outcomes and mechanisms of action. This project evaluates training for medical students entitled ‘Responding to Experienced and Anticipated Discrimination’ (READ), developed to focus on skills in addition to attitudes and knowledge. We

aimed to (i) evaluate the effectiveness of READ with respect to knowledge, attitudes, and clinical communication skills in

responding to mental illness-related discrimination, and (ii) investigate whether its potential effectiveness was mediated via

empathy or/and intergroup anxiety.

Methods: This is an international multisite non-randomised pre- vs post-controlled study. Eligible medical students were

currently undertaking their rotational training in psychiatry. Thirteen sites across ten countries (n=570) were included in

the final analysis.

Results: READ was associated with positive changes in knowledge (mean difference 1.35; 95% CI 0.87 to 1.82), attitudes

(mean difference − 2.50; 95% CI − 3.54 to − 1.46), skills (odds ratio 2.98; 95% CI 1.90 to 4.67), and simulated patient

perceived empathy (mean difference 3.05; 95% CI 1.90 to 4.21). The associations of READ with knowledge, attitudes, and

communication skills but not with simulated patient perceived empathy were partly mediated through student reported

empathy and intergroup anxiety.

Conclusion: This is the first study to identify mediating effects of reduced intergroup anxiety and increased empathy in an

evaluation of anti-stigma training that includes behavioural measures in the form of communication skills and perceived

empathy. It shows the importance of both mediators for all of knowledge, skills, and attitudes, and hence of targeting both

in future interventions.