Abstract
Objective
Stigma decreases healthcare seeking and treatment adherence and increases the duration of untreated psychosis among people with first-episode psychosis (FEP). This study evaluated the efficacy of a brief video-based intervention in reducing stigma among youth toward individuals with FEP and schizophrenia. We hypothesized that the social-contact-based video intervention group would reduce stigma more than written vignette and control groups, and the vignette more than the control group.
Methods
Using Amazon Mechanical Turk, we recruited and assigned 1203 individuals aged 18–30 to either (a) video intervention, (b) written description of the same content (“vignette”), or (c) nonintervention control arm. In the 90-second video intervention, an empowered young woman with schizophrenia described her FEP and the aspects of successful coping with her everyday life difficulties, exposing the viewer to schizophrenia in the context of her personal narrative. Web-based self-report questionnaires assessed stigma domains, including social distance, stereotyping, separateness, social restriction, and perceived recovery.
Results
A MANOVA showed a significant between-group effects for all 5 stigma-related subscales (P < .001). Post hoc pairwise tests showed significant differences between video and vignette vs control for all 5 stigma domains. Video and vignette groups differed significantly on social distance, stereotyping, and social restriction. Secondary analyses revealed gender differences across stigma domains in the video group only, with women reporting lower stigma.
Conclusions
A very brief social contact-based video intervention efficaciously reduced stigma toward individuals with FEP. This is the first study to demonstrate such an effect. Further research should examine its long-term sustainability.
Keywords: FEP, stigma, social contact, schizophrenia, intervention
Introduction
Stigma refers to negative beliefs and stereotypes held toward a specific group of people and adversely affects people with mental illness.1 Worldwide, more than 70% of young people and adults with serious mental illness (schizophrenia, psychosis, and bipolar disorder) receive no mental health treatment, at least in part because of stigma embedded in structural or systemic discrimination.2 People with psychosis experience worse stigma than people with other mental disorders, such as depression or anxiety.3,4 Public stigma refers to negative attitudes and beliefs that motivate individuals to fear, reject, avoid, and discriminate against people with mental illness.5 Individuals with mental illness expect to face prejudice and discrimination (anticipated stigma)6 and internalize public stereotypes of people with mental illness (self-stigma).7 Public, anticipated, and self-stigma decrease healthcare seeking and treatment adherence, and create barriers to pursuing independent living.8
Research has identified stigma as a prominent issue among individuals with first-episode psychosis (FEP) and their awareness of how others perceive them as a main concern.9,10 Shorter duration of untreated psychosis (DUP) among people with FEP is associated with improved short- and long-term prognosis.11,12 Public stigma toward people with FEP has been identified as a barrier to seeking help; therefore, reducing public stigma among young people at risk for or even experiencing FEP could enhance their receptivity to seeking help or treatment.9,13,14 In short, a tool to reduce public stigma toward individuals with FEP could be an effective strategy to reduce DUP.10 To our knowledge, existing studies aimed at reducing public stigma have focused on the general population.15 We know of no studies on reducing public stigma toward people with FEP among young adults.
Research on reducing stigma directed toward individuals with mental illness has shown promise. Thornicroft et al16 found that social contact interventions are the most effective in improving help-seeking behavior and public stigma-related attitudes. Social contact involves interpersonal contact with members of the stigmatized group. Members of the general public who meet and interact with people with mental illnesses are likely to lessen their prejudice. Corrigan et al17,18 identified the most important elements of contact-based antistigma programs: an empowered presenter with lived experience who attains his/her goals and is tailored to target audience characteristics (eg, age and gender). In-person social contact and video-based social contact have shown similar effectivity in improving attitudes toward mental illness.19,20 In-person interventions are difficult to replicate and target relatively small exposure groups, whereas video-based interventions have advantages in low cost, minimal resource use, and ease of dissemination to a wide audience.
However, extant video-based studies have limitations. Interventions have been diffused across a wide range of mental illnesses, with limited focus on psychosis, and research has utilized relatively small sample sizes among specific populations, thereby limiting generalizability. A recent review by Morgan et al21 found that social contact-based video interventions yielded small- to medium-sized stigma reductions immediately postintervention. These effects did not vary by type (in-person vs video) or length of contact (10–65 minutes; average length of 24 minutes). The preponderance (17 of 19; 89%) of these studies was conducted with college students, a nonrepresentative sample, as student research participation is often required for school credit. Sample sizes ranged from 20 to 782 with a median of 97 participants. Similarly, a recent study22 comparing 16-minute video-based social contact conditions to other interventions found reduced stigma toward mental illness in 244 college students exposed to the video-based intervention. In sum, studies that focus on FEP in young populations and use brief scalable interventions are needed.
Because no stigma studies address FEP, and most stigma interventions are lengthy and have evaluated small samples, the current study evaluated the efficacy of a large-scale, state of the art, ultra-brief video-based intervention in reducing stigma among young populations toward people with FEP. Participants were randomly assigned to (a) a brief video-based intervention (“video”), (b) a written vignette intervention containing the same material (“vignette”), or (c) a nonintervention control condition (“control”). Because an audiovisual medium promotes the social contact dimension more than a written description, we hypothesized that the video-based intervention group would reduce stigma more than the written vignette and control groups, and the vignette group more than the control group.
Methods
Participants and Recruitment Procedure
Participants were recruited from Amazon Mechanical Turk (MTurk).23 MTurk, a leading crowdsourcing tool, has been frequently used in medical and psychologic research, including studies assessing treatment satisfaction and brief stigma-reduction interventions.24 The current study required that participants be 18–30 years old and live in the United States. We chose this age range to better understand this age group, as it overlaps with the age of onset of FEP and includes the potential peer group of people with FEP, or even individuals experiencing it themselves. Reducing public stigma in this age group could prevent delays in help-seeking and ease community reintegration. Furthermore, it intervenes in addressing stigma-related experiences when people are still young, rather than letting stereotypical attitudes endure. This age group also cares greatly about what their peers think of them.25 Consistent with recommendations for maximizing data quality, participants were compensated $1.10 for completing the study. The Institutional Review Board of New York State Psychiatric Institute approved the project. Prior to initiating the study, respondents reviewed an informed consent document. Those who agreed to participate were directed to complete the study procedures via Qualtrics.com, a secure, online data-collection platform.
The study goal was to evaluate the efficacy of antistigma interventions using the New York State Psychiatric Institute Center of Practice Innovations (CPI) resources. CPI was founded to advance a behavioral healthcare system whose workforce provides the highest quality and value of evidence-based treatments and services for recovery and wellness to consumers and their families. OnTrackNY, one of the CPI programs, is a coordinated specialty care program for adolescents and young adults with psychosis. CPI resources include a portal for consumers and families that presents video clips of consumers and relatives describing different aspects of coping with their everyday life difficulties. From those materials, we reduced an 11-minute video of an empowered young woman with schizophrenia, who described her first psychotic episode and her struggles with medications and side effects, to 90 seconds. This highlighted her coming across as a human being, presenting her illness in the context of her personal human narrative. The video humanized the illness via social contact. A 3-item quiz, underscoring key learning points, followed the video for half of the participants in the “video” group. We only administered the quiz to half of the group to test whether the quiz itself affected the outcome and to assess the need for such validation in future studies. In hindsight, we found other safeguards to ensure viewer attention: we added a 90-second time delay before the participant could continue to the next part of the study. As the 2 video groups (ie, with and without quiz) showed no outcome differences, we collapsed them into a single cell. The vignette was a written description of the content contained in the video but lacked the direct social contact.
Instruments
Assessment measured public stigma across 5 domains. Overall, we had 19 items, but we analyzed each of the 5 subscales separately. Six items assessed social distance and 3 items assessed social restriction (derived from Boyd et al).26Social distance was divided into casual (eg, “Would you be willing to have someone with schizophrenia as a close friend?”) and intimate social distance (eg, “Would you be willing to have someone with schizophrenia marry your child?”). The overall scale has good internal consistency (alpha = .89). Social restriction assessed the participant’s perception of whether a person with schizophrenia should marry and have children (Cronbach’s alpha = .67). Four items of Separateness (or “differentness”) came from Phelan27 (eg, “Someone with arthritis or a broken leg has just one thing wrong with them, but a person with schizophrenia is very different from other people”; Cronbach’s alpha = .81). For the Stereotyping domain, we drew items from the General Social Survey28 to assess the perception of a person with schizophrenia’s: ability to (1) make treatment decisions and (2) manage money, and the likelihood of (3) violence toward others and (4) violence toward oneself (Cronbach’s alpha = .62). Two items (of 41 in the original questionnaire) assessing Perceived recovery from a community member’s perspective addressed the perception of a person with schizophrenia’s ability to meet current personal goals and have a plan for staying well (from the Recovery assessment scale29; alpha = .74). Responses range from 1 (eg, “strongly agree”) to 4 (eg, “strongly disagree”). Two items queried whether the participant had a friend or family member with serious mental illness, and if so, the level of intimacy or closeness with this individual.30
Analysis
Data were analyzed using SPSS 26.0. We used Pearson’s Chi-square to compare demographic variables among groups. One-way ANOVAs and MANOVA compared mean score differences across the 3 groups; when between-group differences were found, post hoc tests were used to compare each pair. We next compared the 19 individual items, with Bonferroni correction for multiple comparisons yielding a corrected P-value significance threshold of .05/19 = .003. As an exploratory analysis, independent sample t-tests compared male and female results within each group.
Results
Sample Characteristics
The study sample included 1203 participants, who were randomly and proportionally divided into 4 study groups. Fifteen participants were excluded for having completed the assessment battery in less than 60 seconds, after statistical tools showed that the results from this subset were too random and inconsistent to be trusted, resulting in 1188 participants (see table 1). The study population had a mean age of 26.4 (±2.9) years and included a slight majority of women (n = 634, 53%). Only 204 (17%) identified as Hispanic; 764 (64%) reported white race and 276 (23%) Asian; only 83 (7%) described themselves as African American. Study arms did not significantly differ by sex, age, race, or ethnicity (table 1).
Table 1.
Demographics, n (%)
| Items | Video n = 596 |
Vignette n = 299 |
Control n = 293 |
Total n = 1188 | P | |
|---|---|---|---|---|---|---|
| Gender— female | 317 (53) | 160 (54) | 157 (54) | 634 (53) | 2.27a | .97 |
| Hispanic | 98 (16) | 59 (20) | 47 (16) | 204 (17) | 3.15a | .53 |
| Race | ||||||
| White | 388 (65) | 192 (64) | 184 (63) | 764 (64) | 6.46a | .78 |
| Asian | 133 (22) | 67 (21) | 76 (26) | 276 (23) | ||
| African American | 39 (7) | 27 (9) | 17 (6) | 83 (7) | ||
| Native American | 13 (2) | 4 (1) | 4 (1) | 21 (2) | ||
| Other | 15 (3) | 4 (1) | 9 (3) | 28 (2) | ||
| Familiarity with a person with SMI | 201 (38) | 120 (44) | 114 (43) | 435 (41) | 3.77a | .15 |
| Mean age (SD) | 26.5 ± 2.8 | 26.4 ± 2.8 | 26.1 ± 3 | 26.4 ± 2.9 | 1.60b | .20 |
Note: SMI, serious mental illness.
aPearson Chi-square.
bOne-way ANOVA.
As hypothesized, study groups significantly differed in outcome (figure 1). A MANOVA showed a significant between-group effects for the total scores of all 5 stigma-related subscales (Wilks’ lambda F = 15.85, P < .001). One-way ANOVAs also showed significant between-group effects for the total scores of all 5 stigma-related subscales: social distance (F = 46.2, P < .001), social restriction (F = 16.3, P < .001), stereotyping (F = 52.4, P < .001), separateness (F = 5.8, P = .001), and perceived recovery (F = 23.3, P < .001). Post hoc tests showed significant differences between video vs control and vignette vs control for all 5 stigma domains. Video vs vignette significantly differed on social distance, stereotyping, and social restriction.
Fig. 1.
Total mean scores (SD) of stigma questionnaires across groups.Note: A higher score indicates a higher stigma; post hoc between-groups differences, one-way ANOVA, *P < .001; **P < .01; ***P < .05.
Table 2 presents mean scores and percentages of the 19 stigma items and pairwise mean score comparisons of the video, vignette, and control groups. For clarity, we collapsed the values into agree (combining “strongly agree” and “agree”) and disagree (“strongly disagree” and “disagree”). For example, 93% of video group participants would agree to have someone with schizophrenia as a neighbor, compared with 86% and 72% in vignette and control groups, respectively. Of the 19 items, 18 (95%) differed significantly between video and control groups, 15 (79%) differed significantly between vignette and control groups, and 10 (53%) differed significantly between video and vignette groups.
Table 2.
Comparison Between Video (n = 596), Vignette (n = 299), and Control (n = 293) Group Scores on Stigma Scales
| Pairwise Comparisons | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| Video | Vignette | Control | Video- Control | Vignette- Control | Video- Vignette | ||||
| Items | Mean | % | Mean | % | Mean | % | |||
| Social distance (Cronbach’s alpha = .89): Would you be willing to… | |||||||||
| …have someone with schizophrenia as a neighbor? | 1.5 ± 0.7 | 93 | 1.7 ± 0.8 | 86 | 2.0 ± 0.9 | 72 | * | * | ** |
| …be close friends with someone with schizophrenia? | 1.6 ± 0.7 | 89 | 1.8 ± 0.8 | 82 | 2.0 ± 0.9 | 71 | * | *** | * |
| …have a person with schizophrenia working closely with you on a job? | 1.6 ± 0.7 | 90 | 1.8 ± 0.8 | 84 | 2.1 ± 0.9 | 68 | * | * | ** |
| …allow a child of yours to date a person with schizophrenia? | 1.9 ± 0.9 | 80 | 2.4 ± 1.0 | 59 | 2.5 ± 1.0 | 51 | * | ns | * |
| …allow a child of yours to marry a person with schizophrenia? | 1.9 ± 0.9 | 77 | 2.3 ± 1.0 | 60 | 2.5 ± 1.0 | 52 | * | ns | * |
| …allow a child of yours to have a baby with a person with schizophrenia? | 2.0 ± 1.0 | 93 | 2.4 ± 1.0 | 86 | 2.6 ± 1.0 | 72 | * | *** | * |
| Subscale mean score and percentage | 1.8 ± 0.7 | 87 | 2.0 ± 0.8 | 76 | 2.3 ± 0.8 | 64 | * | ** | * |
| Stereotyping (Cronbach’s alpha = .62) | |||||||||
| How able is a person with schizophrenia to… | |||||||||
| …make his own decisions about the treatment he should receive? | 1.5 ± 0.6 | 94 | 1.7 ± 0.7 | 89 | 2.0 ± 0.7 | 79 | * | * | * |
| …make his/her own decisions about managing his own money? | 1.5 ± 0.6 | 94 | 1.6 ± 0.7 | 90 | 2.0 ± 0.8 | 78 | * | * | ** |
| How likely is it that a person with schizophrenia would… | |||||||||
| …do something violent toward other people? | 2.2 ± 0.6 | 74 | 2.3 ± 0.6 | 66 | 2.4 ± 0.6 | 56 | * | *** | ** |
| …do something violent toward himself? | 2.7 ± 0.8 | 39 | 2.8 ± 0.7 | 32 | 3.1 ± 0.8 | 20 | * | * | ns |
| Subscale mean score and percentage | 1.9 ± 0.5 | 75 | 2.1 ± 0.4 | 69 | 2.3 ± 0.5 | 58 | * | * | * |
| Separateness (Cronbach’s alpha = .81) | |||||||||
| When you think of a person with schizophrenia, how different do you think he is from other people? | 2.5 ± 0.8 | 51 | 2.5 ± 0.8 | 50 | 2.8 ± 0.8 | 31 | * | * | ns |
| Although a person with schizophrenia may seem just like everyone else, he is actually different in important ways | 2.8 ± 0.9 | 34 | 2.8 ± 0.8 | 34 | 2.9 ± 0.8 | 28 | ns | ns | ns |
| Someone with arthritis has just one thing wrong with them, but a person with schizophrenia is very different from other people | 2.4 ± 1.0 | 52 | 2.4 ± 0.9 | 57 | 2.6 ± 0.8 | 41 | * | ** | ns |
| Although he may be like other people in many ways, a person with schizophrenia is fundamentally different from other people | 2.6 ± 0.9 | 42 | 2.6 ± 0.9 | 43 | 2.8 ± 0.9 | 31 | ** | *** | ns |
| Subscale mean score and percentage | 2.6 ± 0.7 | 45 | 2.6 ± 0.7 | 46 | 2.8 ± 0.7 | 33 | * | * | ns |
| Social restriction (Cronbach’s alpha = .67): A person with schizophrenia… | |||||||||
| …could be trusted to babysit small children | 2.4 ± 0.9 | 61 | 2.6 ± 0.9 | 52 | 2.8 ± 1.0 | 39 | * | *** | ** |
| …shouldn’t get married–ie, he should stay single | 1.6 ± 0.9 | 81 | 1.8 ± 1.0 | 78 | 1.9 ± 1.0 | 74 | * | ns | ns |
| …shouldn’t have children of his own—ie, he should remain childless | 1.9 ± 1.0 | 71 | 2.0 ± 1.0 | 70 | 2.3 ± 1.0 | 58 | * | ** | ns |
| Subscale mean score and percentage | 2.0 ± 0.7 | 71 | 2.1 ± 0.7 | 67 | 2.3 ± 0.7 | 57 | * | ** | *** |
| Perceived recovery (Cronbach’s alpha = .74): I believe that a person with… | |||||||||
| …schizophrenia has a plan for how to stay well | 1.7 ± 0.8 | 89 | 1.8 ± 0.8 | 87 | 2.1 ± 0.8 | 75 | * | * | ns |
| …schizophrenia can meet his current personal goals | 1.5 ± 0.7 | 92 | 1.6 ± 0.7 | 92 | 1.8 ± 0.8 | 82 | * | * | ns |
| Subscale mean score and percentage | 1.6 ± 0.7 | 91 | 1.7 ± 0.6 | 90 | 2.0 ± 0.7 | 79 | * | * | ns |
Note: Scores ranged from 1 to 4, with higher scores indicating higher stigma; the percentage indicates categorical agreement with the suggested content, with higher percentage indicating less stigma; *P < .001; **P < .01; ***P < .05.
In response to “Do you have a friend or a family member diagnosed with serious mental illness?,” 435 (41%) replied “Yes” and 631 (59%) replied “No.” Proportions of yes/no did not differ across study arms (table 1). While stigma scores did not differ between “yes” and “no” responders within the video group, independent samples t-tests showed significant differences within the vignette and control groups. For example, on the social distance scale, people who reported having a friend or family member with schizophrenia showed lower stigmatic attitudes in both vignette and control groups than respondents who did not report this (P < .001).
To better understand the specific components driving these changes, we conducted a secondary item-level analysis. As the protagonist in the video and vignette was an African American woman, we examined whether these factors had a greater influence on people with similar characteristics. No gender differences were found between assessments of the vignette and control groups, but women showed lower stigma than men across all assessments in the video groups (figure 2). No ethnic or racial differences were found, but only 83 (7%) of respondents were African American, and only 39 of them were assigned to video intervention, limiting the power to find a difference.
Fig. 2.
Gender differences in the video intervention group only across stigma questionnaires.Note: A higher score indicates higher stigma; independent t-test, *P ≤ .001; **P < .01; ***P < .05.
Discussion
Our randomized clinical trial tested the utility of a simple, very brief intervention in reducing public stigma toward individuals with FEP and schizophrenia among 1203 young adults. As hypothesized, the video-based intervention group yielded lower rates of stigma than the written vignette and control groups, and the written vignette yielded lower stigma than the control group. This is consistent with previous literature emphasizing the greater effectiveness of contact-based interventions.16,31 This study, the first to demonstrate effectiveness in reducing stigma toward individuals with FEP among young adults, used an extremely brief intervention, minimal resources, is easily disseminated, and is accessible to a wide audience (eg, OnTrack Recovery Videos- https://www.ontrackny.org/Videos).
How can a 90-second video produce such change? The video protagonist, a 22-year-old African American woman who experienced psychosis, was diagnosed with schizophrenia, and shared her story with younger people (18–30), is an appealing young spokesperson who fulfills all interpersonal contact criteria.17 In a direct and honest manner, she presents the story of a young adult with psychosis who has successfully engaged in treatment and lives a meaningful and productive life. This hopeful, uplifting story reduced public stigma and might promote help-seeking among individuals with FEP.14,32 Future studies should examine whether this video-based approach, portraying patient recovery stories, has the potential to simultaneously reduce public stigma and provide insight into psychotic symptoms, thus enhancing detection of psychosis and shortening DUP.13
Previously tested video interventions have been far longer than ours. A study among university students (n = 259) compared a 30-minute social contact-based video to a self-instructional internet search to reduce mental illness-related stigma.19 The study included 5 web-based sessions at 2-month intervals and a 12-month follow-up assessment. The video group demonstrated greater short- and long-term efficacy. While repeated long videos may be suitable to relatively small samples of university-based populations, they might be not feasible for larger, general population samples. In an era of excessive social media use and low frustration tolerance, especially among youth, content needs to be succinct and direct. Notably, we did not compare videos of different lengths, but it seems possible that even briefer videos might be effective. Ninety seconds appears ultra-brief relative to previous stigma interventions, but it lasts more than triple the length of a typical television commercial, which has also been known to alter perceptions.33 To our knowledge, ours is the only study to test the efficacy of a very brief, large scale, contact-based intervention for young adults. Future research should attempt to refine the maximum length for different modes of delivery.
While the video and vignette groups both differed from the control group across all 5 stigma domains, the video and vignette groups separated only for social distance, stereotyping, and social restriction, whereas the separateness and perceived recovery scales showed no difference. One possible explanation lies within the core difference between video and vignette: the audiovisual aspect. Seeing and hearing an empowered young woman describe her battles and barriers may arouse emotions that enhance the viewer’s identification with the presenter. A written vignette, in contrast, might lack such emotional immediacy.34 While this process might be essential to reduce the (social) distance (eg, “Would you willing to have someone with schizophrenia as a neighbor?”) and stereotypes (eg, “How likely is a person with schizophrenia to do something violent toward himself/other people?”), it may not be necessary to change knowledge-based perceptions such as separateness and perceived recovery (eg, “I believe that a person with schizophrenia has a plan for how to stay well”).
Our finding that respondents who reported having a friend or family member with schizophrenia had less stigmatic attitudes than people not reporting this concords with other studies.30,35 However, this difference was limited to vignette and control groups; we found no difference in the video group. This absence suggests that identifying with an empowered presenter in a video might be as effective as having a friend or family member with schizophrenia. Unfortunately, we did not measure the stigma preintervention. Future studies should explore whether and how social contact-based video interventions can play such a role.
A secondary, item-level analysis showed that the video had a greater influence on women across all scales. This gender difference, found only in the video group, strengthens our hypothesis that identification with the video presenter (a woman identifying with a woman presenter) enhances the social contact effect and reduces stigma. While other studies36 have shown that stigma attitudes may differ across sociodemographic groups, to our knowledge, no prior studies have linked sociodemographic variables to stigma change. Future research should explore specific characteristics such as the presenter’s age, ethnicity, race, and their influence on reducing stigma.
Limitations
Our study has several limitations. First, study findings might be limited to MTurk participants, who differ slightly from the general population.21 For example, 64% of participants reported white race and 23% reported Asian origin, diverging from the distribution of the US population. Second, our preliminary proof of concept study lacked a baseline assessment, precluding direct measurement of actual change. However, as participants were randomly assigned to study arms, and study arms did not differ in gender, age, ethnicity, or race, we infer change by study arm. Third, the video featured an African American presenter, but we enrolled too few African American participants to measure an expected racial effect paralleling that for gender. Lastly, our study did not evaluate longer-term effects of our brief video intervention. Further studies are needed to examine its sustainability.
Conclusions
A 90-second social contact-based video intervention effectively reduced stigma toward individuals with FEP and schizophrenia more than comparison conditions. We reduced stigma associated with mental illness by presenting a human face rather than a “brain disease.” This is the first study to examine such an effect in a young sample and also the first to employ such a brief antistigma intervention. Women showed a greater stigma reduction solely in the video group, supporting our hypothesis that identification with the video protagonist reduces stigma. This simple, brief, easy to disseminate video-based intervention has the potential to increase the likelihood of seeking services and improving access to care among people with FEP and ultimately reduce DUP. More studies are required to examine its long-term sustainability and its applicability to individuals in other age groups.
Acknowledgment
We thank the video participant, who shared her story and contributed to stigma reduction.
Funding
None.
Data Sharing Statement
There is no ethical approval for data sharing.
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