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Fighting psychiatric stigma in the classroom: The impact of an educational intervention on secondary school students' attitudes to schizophrenia
M. Economou, E. Louki, L. E. Peppou, C. Gramandani, L. Yotis and C. N. Stefanis Int J Soc Psychiatry 2012 58: 544 originally published online 9 August 2011 DOI: 10.1177/0020764011413678 The online version of this article can be found at: http://isp.sagepub.com/content/58/5/544

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ISP58510.1177/0020764011413678Economou et al.International Journal of Social Psychiatry

E CAMDEN SCHIZOPH

Article

Fighting psychiatric stigma in the classroom: The impact of an educational intervention on secondary school students attitudes to schizophrenia
M. Economou,1 E. Louki,1 L. E. Peppou,1 C. Gramandani,1 L. Yotis1 and C. N. Stefanis1

International Journal of Social Psychiatry 58(5) 544551 The Author(s) 2011 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0020764011413678 isp.sagepub.com

Abstract Background: Adolescents constitute an appealing target group for fighting stigma and discrimination surrounding mental illness, since it is during this developmental period that adult attitudes about mental illness are formed and consolidated. Aim: The aim of the present study was twofold, to explore adolescents beliefs and attitudes to schizophrenia and to evaluate the effectiveness of an anti-stigma intervention in altering them. Methods: A total of 616 high school students participated in the study, divided into a control condition and an antistigma intervention group. Data were collected at three time points: before the intervention, upon its completion and at a 12-month follow-up. Results: Baseline measurements indicated that students espoused certain stereotypical beliefs about patients with schizophrenia and were reluctant to interact with them on some occasions. Upon completion of the intervention, positive changes were recorded in students beliefs, attitudes and desired social distance; however, only the changes in beliefs and attitudes were maintained after one year. Conclusion: For anti-stigma interventions to be effective, they should be continuously delivered to students throughout the school years and allow for an interaction between students and patients. Health promotion programmes might be an appropriate context for incorporating such interventions. Keywords schizophrenia, intervention, stigma, attitudes, adolescents, health promotion

Introduction
Stigma surrounding mental illness has been identified as the main barrier in the provision of mental health care and the delivery of effective treatment (Sartorius, 2002). A growing body of research has revealed that stereotypical beliefs and prejudicial attitudes are consistently associated with patients reluctance to seek treatment (Vogel, Wade, & Hackler, 2007), low self-esteem (Link, Struening, Neese-Todd, Asmussen & Phelan, 2001) and social impairment (Perlick et al., 2001), and they frequently lead to discrimination in fundamental areas of life, such as housing and employment (Corrigan, 2005). Due to its detrimental repercussions, large international organizations have declared stigma a major public health challenge (Sartorius, 2004; World Health Organization, 2001) and have called for countries to develop effective strategies for diminishing it. Corrigan and Penn (1999) have argued that the three most effective approaches for reducing stigma attached to mental illness are protest, education and contact. Among the three, education is the approach that has been most widely used (Corrigan et al., 2001). Educational programmes usually involve a presentation of factual and evidence-based information about the features of psychiatric disorders and their treatment. Although education by itself is not as effective as personal contact in decreasing stigma (Drolen, 1993), it allows the public to make informed
1University

Mental Health Research Institute (UMHRI), Athens, Greece

Corresponding author: M. Economou, University Mental Health Research Institute, 2 Soranou tou Efesiou St., 11527 Papagou, Athens, Greece Email: stigma@epipsi.gr

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Economou et al. choices about mental illness and hence can act as the first step towards attitudinal and behavioural change (Corrigan, 2004b). Corrigan and Penn (1999) have shed light on this strand of research by identifying four key components of successful educational interventions: the provision of personal information about the patient with mental illness; a direct attack of myths; an increase in empathy levels by simulation; and an in-depth discussion on the topic. In addition, to increase the effectiveness of any anti-stigma approach, including an educational one, the intervention should target specific population groups (Corrigan, 2004a; Thornicroft, 2006). With regard to young population groups, converging evidence has supported that school-based anti-stigma initiatives may constitute an effective vehicle for advancing knowledge about mental illness and improving attitudes towards the patients who suffer from it (Pinfold, Toulmin, Thornicroft, & Huxley, 2003; Rickwood, Cavanagh, Leigh, & Sakrouge, 2004; Schachter et al., 2008; Schulze, RichterWerling, Matschinger, & Angermeyer, 2003; Stuart, 2006). Children and adolescents have emerged as a promising target group for anti-stigma interventions, because throughout this developmental period attitudes to mental illness are consolidated. Various studies have demonstrated that children do not yet have a clear idea of what mental illness denotes (Corrigan & Watson, 2007), and that the personality traits that constitute the foundation for stereotype endorsement are not well entrenched until adolescence (Flavell, Miller, & Miller, 2001). Therefore, by altering unfavourable and rejecting attitudes among children and adolescents, one can prevent them from becoming adults who hold traditional stereotypical beliefs about people with mental illness and hence stigmatize them. Furthermore, addressing children and adolescents merits special attention in light of the high prevalence of psychiatric disorders in this population (Schulze et al., 2003; Stuart, 2006). Evidence from the World Health Organization (2005) suggests that while one in five adolescents experiences a mental disorder, only 20% of them will seek professional help for fear of being labelled as mentally ill. This finding is important given that many psychiatric disorders emerge during adolescence, such as obsessive compulsive disorder (Maggini et al., 2001) and schizophrenia (Thomsen, 1996). In spite of the significance of this type of intervention, the literature on the effectiveness of anti-stigma initiatives in children and adolescents is scarce (Schachter et al., 2008). The limited number of studies on the topic have indicated that prior to the intervention, the majority of students are either unsure about the correctness of stereotypical views about patients with psychiatric disorders or less rejecting towards them in comparison to adults; with variables such as gender and familiarity with mental illness playing a prominent role in stigma endorsement (Corrigan et al., 2005; Ng & Chan, 2002; Pinfold et al., 2003; Schulze et al., 2003; Watson et al., 2004). In terms of effective interventions,

545 education has been shown to yield improvements of short duration in attitudes towards mental illness in adolescents (Ng & Chan, 2002; Schulze et al., 2003; Watson et al., 2004; Williams & Pow, 2007). However, social distance measures, which constitute the most widely used index of stigmatization (Jorm & Oh, 2009), have been found to display the greatest resistance to change upon completion of the educational intervention (Pinfold et al., 2003; Schulze et al., 2003). Recent evidence has indicated that when personal contact with a patient with mental illness, either in vivo or in a video, is added to education, attitudes towards patients are improved and desired social distance from them is remarkably reduced (Chan, Mak, & Law, 2009; Schachter et al., 2008; Stuart, 2006) The anti-stigma programme, run by the University Mental Health Research Institute, has designed and implemented a series of anti-stigma interventions in adolescents within the framework of World Psychiatric Association Open the Doors global program against stigma and discrimination because of schizophrenia. Due to the focus of the programme on schizophrenia at the time (Economou, Gramandani, Richardson, & Stefanis, 2005; Economou, Richardson, Gramandani, Stalikas, & Stefanis, 2009), the interventions addressed the stigma surrounding severe mental illness in general and schizophrenia in particular. The aim of the intervention was to advance students knowledge about schizophrenia, to improve their attitudes towards the patients who suffer from it and to reduce their desired social distance levels. Consistent with this, the intervention aimed to yield changes in all three dimensions of stigma, namely knowledge, attitudes and behaviour (Thornicroft, 2006); however, changes in the behaviour dimension were assessed indirectly by employing a social distance measure, which constitutes a proxy of behavioural intention. To achieve its aims, the initial intervention protocol incorporated a combined education and personal contact strategy, in line with the literature underscoring its effectiveness (Chan et al., 2009; Schachter et al., 2008; Stuart, 2006). However, a number of objections and complaints on the part of parents, school principals and teachers necessitated changes in the protocol resulting in the elimination of the personal contact components. Therefore, in its final form, the intervention was largely educational in nature but it did entail some narratives of patients with schizophrenia read by a mental health professional. To optimize the interventions effectiveness, its content was based on Corrigan and Penns (1999) recommendations. In the context of patient narratives, personal information about the patient and his/her aftercare was provided to students, the myths that surround schizophrenia were attacked one by one, students empathic feelings towards patients were enhanced by role-play exercises and an in-depth discussion on the topic was conducted. Consistent with these, the present study set the twofold aim of exploring high school students beliefs, attitudes and desired social distance

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546 from patients with schizophrenia (PwS) at baseline and subsequently to evaluate the impact of an anti-stigma intervention in improving them upon its completion and at a 12-month follow-up.

International Journal of Social Psychiatry 58(5) invited students to write them all on the blackboard and subsequently attacked them one by one by providing accurate and scientific information in an age-appropriate language. In this context, the coordinators elaborated on the prodromal symptoms of the disorder, its course and the available treatments for it. This scientific information was complemented by patients narratives, read by the professionals, which underscored patients subjective experience of the disorder and the burden associated with it. Students were then asked to role-play being in the patients position, leading to a discussion on the evoked thoughts and feelings as the next step of the intervention. During the second part of the programme, the focus of the discussion was on patients experiences of stigma, where narratives about being rejected due to schizophrenia were read to the students. Among the topics discussed afterwards was the role of the media in perpetuating stigmatization of the disorder and the often demeaning expressions used when people describe PwS. A number of stigmatizing words, most of which stemmed from the cards students filled in at the beginning of the programme, were written on the blackboard. Then, the coordinators elaborated on alternative ways of talking about PwS in a respectful manner. Students crossed out all stigmatizing words and wrote on the blackboard the motto speak the language that respects not the language that hurts. The programme was completed with a collective drawing activity. A large roll of paper was placed in the middle of the classroom with students sitting around it, so that students could express on it their feelings and thoughts about the programme.

Methods Participants
A total of 616 secondary school students participated in the present study, recruited from 11 public schools in Athens. The schools were selected from a list provided by the Ministry of Education, which encompassed public schools with a health promotion programme in their curriculum. Out of the 35 schools enlisted, 13 of them were in Athens and particularly situated in areas of diverse socioeconomic background. Formal letters along with the treatment protocol were sent to the school principals and after three months, the research team paid them a visit to discuss the project. Of the 13 schools, only 11 expressed an interest in the study. In each of these schools, a class was randomly selected for receiving the intervention and another one, within the same grade, for receiving the control condition. Overall, 308 students attended the control talk and 308 the anti-stigma intervention. Nonetheless, due to missing some students at follow-up, only the data of 580 students were analysed: 281 from the control group and 299 from the intervention. Congruent with this, the response rate was 94.16% for the whole sample, 91.23% for the intervention group and 97.08% for the control group. The reason of attrition was mainly students absence from class the day the follow-up data were gleaned. Among the 580 students, 228 (48.6%) were boys and 241 (51.4%) were girls, with their age ranging from 13 to 15 years old (M = 13.84, SD = 0.82). One hundred and twenty five (125; 26.7%) of them reported having a relative or close friend with mental illness.

Procedure
After presenting themselves to the class and making a short introduction about the scope and layout of the intervention, two professionals administered the baseline questionnaires. Students were reassured that their responses would remain confidential. After the questionnaires were collected, the experimental group underwent the anti-stigma workshop while the control group attended a talk about nutrition and healthy living; teachers were not present in the classroom for either talk. Upon completion of the talk, questionnaires were distributed again, while 12 months after the completion of the intervention, the research team visited the schools for the last time and gleaned the follow-up data. The research protocol was approved by the EPIPSI Ethics Committee in accordance with the provisions of Helsinki in 1995 and informed consent was obtained by both the students and their parents.

Intervention
The intervention, a two-hour semi-structured programme, was delivered by two professionals of the anti-stigma programme, an educational psychologist and a psychiatrist, especially trained in group dynamics. The programme consisted of two parts and was delivered in such a way as to encourage the active involvement of all students. During the first part, a card was distributed to students asking them to make a note of the word, emotion and colour that comes first in their mind when they hear the term mental illness. This gave rise to an open discussion on the topic, where students freely expressed their beliefs and feelings about schizophrenia and PwS. From this initial discussion, a number of stereotypes and myths about schizophrenia and the patients who suffer from it emerged; namely that PwS are dirty, dangerous, mentally retarded, have split personality and cannot work. The coordinators of the programme

Measures
Participants beliefs and attitudes were assessed by using selected questions from the Alberta Pilot Site Questionnaire Toolkit (Thompson et al., 2002) adapted for high school

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Economou et al. students. The self-reported instrument comprised two parts, one exploring beliefs and attitudes towards schizophrenia and PwS, and another addressing the degree of desired social distance from them. The beliefs and attitudes part encompassed 11 items, rated on a four-point Likert scale (1 = never, 4 = always), with some of them being negatively phrased in order to avoid response bias (e.g. PwS can be creative). Similarly, the social distance section of the instrument consisted of seven items, rated on a fourpoint Likert scale (1 = definitely no, 4 = definitely yes), with some of them being also negatively phrased in order to avoid bias (e.g. Would you invite someone with schizophrenia to your party?). For both sections, a composite score was calculated by adding up the responses to all items, after having reversed the negatively phrased items (subtracting their rating from 5). For both composite scores, higher values indicated more stereotypical beliefs and negative attitudes towards schizophrenia and PwS as well as a greater desired social distance from them. A reliability analysis utilizing Cronbachs indicated moderate internal consistency for both composite scores (for beliefs, = 0.60.76 and for social distance, = 0.760.78).

547 A multiple linear regression model on follow-up scores was used in order to identify which factors could significantly predict students follow-up results.

Results
The two groups (control and intervention) did not display significant differences in terms of their basic demographic variables, such as gender, age and personal acquaintance with someone with serious mental illness (p > .05).

Baseline beliefs, attitudes and social distance

The two groups did not differ significantly with regard to the distribution of their baseline responses to all items (p > .05). To increase the statistical power of the analysis, data were pooled in such a way that two categories were formed: always/often and seldom/never for the beliefs and attitudes section and definitely/probably yes and definitely/ probably no for the social distance section. The majority of students espoused the stereotypical view of a PwS talking to him/herself or shouting in city streets (80.1%). Similarly, a high percentage of students reported that PwS always/often suffer from split or multiple personalities (70.9%) or cannot work at regular jobs (81.2%). Furthermore, one in two viewed PwS as dangerous (51.25% believed this is always/often the case) and a public nuisance (50.5% answered always or often). Interestingly, a relatively high percentage of the sample held the positive view that PwS can be creative (67.15%), can be successfully treated outside of the hospital in the community (67.95%) and need prescription drugs to control their symptoms (72.6%). In terms of social distance items, the vast majority of students would not fall in love with a PwS (86.8%) nor would share their room with him/her during a school excursion (81.85%). Furthermore, one in two would not invite a PwS to their party (41.4% would probably/definitely do so). Nonetheless, only 35.55% would be upset or disturbed to be in the same class with a PwS, 46.75% would be afraid to talk to him/her, while 70.5% would start a friendship with him/her. When composite scores were calculated, no gender effect on beliefs, attitudes and social distance at baseline emerged (t = 0.3, p > .05 for the beliefs and attitudes section and t = 0.89, p > .05 for the social distance section). By contrast, previous contact with a person with a severe mental illness was found to differentiate in a significant manner the social distance scores at baseline (t = -2.57, p < .01).

Statistical analysis
For a descriptive analysis of students baseline beliefs, attitudes and social distance answers, percentages of pooled responses for each item were used. For the analysis of associations between gender and familiarity with mental illness on the one hand, and baseline beliefs, attitudes and social distance measures on the other, two composite scores were calculated: one for beliefs and attitudes and another for social distance. A t test for independent samples was then used to reveal any differences. In order to evaluate the short-term effect of the intervention on beliefs, attitudes and social distance, the mean baseline score for each item was compared to the mean post-intervention score for the corresponding item by using a repeated measures t test analysis. Similarly, to evaluate the longterm effectiveness of the intervention, a pairwise t test was used between the baseline mean scores for each item and its corresponding follow-up score. The rationale for conducting item analysis in the study was to identify which beliefs, attitudes and social interactions displayed the greatest change and which displayed the least. In addition, for the beliefs and attitudes section of the instrument, the reliability analysis demonstrated wide variability in the values of Cronbachs (range 0.60.76) and as a result of this, analysis on a scale level was contentious and hence was avoided. On the contrary, as social distance scales have been empirically supported in terms of their psychometric properties, the results pertaining to the social distance items were analysed on a scale level as well. The effect of the intervention on the social distance composite score was assessed using repeated measures ANOVA.

Intervention effect
To evaluate the effectiveness of the intervention, students answers before and after the workshop were compared for the experimental and control groups separately.

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548

International Journal of Social Psychiatry 58(5)

Table 1. Mean item scores for beliefs and attitudes section at baseline, post-intervention and follow-up time points. Beliefs and attitudes PwS suffer from split or multiple personalities PwS tend to be mentally retarded or of lower intelligence PwS hear voices telling them what to do PwS can be seen talking to themselves or shouting in city streets PwS are dangerous to the public PwS are a public nuisance due to panhandling, poor hygiene or odd behaviour PwS can be successfully treated outside of the hospital, in the community PwS can be successfully treated without drugs using psychotherapy PwS can work at regular jobs PwS can be creative Baseline M (SD) 2.97 (0.69) 2.4 (0.83) 2.79 (0.77) 3.27 (0.69) 2.61 (0.82) 2.63 (0.9) 3.01 (0.74) 2.6 (0.86) 1.7 (0.78) 2.85 (0.72) Post-intervention M (SD) 1.78 (0.95)* 12-month follow-up M (SD) 2.5 (0.91)* 2.18 (0.83)* 2.86 (0.97) 3.04 (0.78)* 2.05 (0.85)* 2.37 (0.93)* 3.13 (0.7) 2.70 (0.86) 1.94 (0.86)* 3.07 (0.75)*

1.76 (0.82)* 3.1 (0.85)* 3 (0.78)* 1.85 (0.83)* 2.13 (0.98)* 3.32 (0.85)* 2.75 (0.92) 1.83 (0.89)* 3.45 (0.73)*

Mean scores per item for the intervention group ranged from 1 (almost never) to 4 (almost always) *p < .01 difference compared to baseline

Table 2. Mean item scores for social distance section at baseline, post-intervention and follow-up time points. Social distance Would you be afraid to talk to a PwS? Would you be upset or disturbed to be in the same class with a PwS? Would you start a friendship with a PwS? Would you invite a PwS to your party? Would you feel embarrassed or ashamed if your friends knew that someone in your family had schizophrenia? Would you share your room on a school excursion with a PwS? Would you fall in love with a PwS? Baseline M (SD) 2.45 (0.91) 2.22 (1) 2.95 (0.91) 2.22 (0.9) 2.17 (1.11) 1.72 (0.87) 1.49 (0.81) Post-intervention M (SD) 1.97 (0.91)* 1.74 (0.8)* 3.15 (0.92)* 2.64 (0.94)* 1.93 (1.12)* 2.35 (0.98)* 1.88 (1)* 12-month follow-up M (SD) 2.28 (0.83) 1.85 (0.86)* 2.72 (0.89) 2.44 (0.89)* 2.08 (1.04) 1.93 (0.85)* 1.73 (0.92)

Mean scores per item for the intervention group ranged from 1 (definitely no) to 4 (definitely yes) *p < .01 difference compared to baseline

Short-term effect: Upon completion of the intervention. For the experimental group, beliefs and attitudes were improved in all items but one (PwS can be successfully treated without drugs using psychotherapy; Table 1) and this cannot be explained by variables other than the intervention, since the control group did not manifest the same pattern of results (p > .05 for all items). Nonetheless, even upon completion of the intervention, students still subscribed to some negative stereotypes about PwS. Specifically, the majority of students still believed that PwS can be seen talking to themselves or shouting in city streets (mean score = 3, which is higher than the neutral point 2.5 and closer to the extreme always) and cannot hold a job in an open labour market (mean score = 1.83, which is below the neutral point 2.0 and closer to the extreme never).

Likewise for the social distance items, there was a significant change in all items for the experimental group (Table 2), whereas no significant changes were recorded for the control group (p > .05 for all items). However, even after the intervention the mean score for the item Would you fall in love with a PwS? was 1.88, which is below the neutral point 2.0 and closer to the extreme definitely no. Long-term effect: Follow-up. In order to address the longterm effect of the intervention, the answers at the pre-intervention and follow-up time points were compared. With regard to students beliefs and attitudes to PwS, a gradual worsening was observed from post-intervention mean item scores to the corresponding follow-up scores. Nonetheless, the statistical analysis revealed that follow-up scores were significantly different from baseline scores on

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Economou et al.
Social distance 19 17 15 13 11 9 7 5 3 1

549 population in Greece (Economou, Gramandani et al., 2005; Economou et al., 2009). In spite of dissimilarities in the sampling methods between the current study and those carried out in adults, one can observe that adults are more stigmatizing and negative towards PwS. Among the adolescents, 51.25% held the view that PwS are dangerous in contrast to 70.1% of adults, after controlling for urbanrural differences. Similarly, 50.5% of adolescents were found to deem PwS a public nuisance, while this figure is 62.9% in adults. This finding is consistent with other studies that have indicated that adolescents hold more favourable attitudes than adults to people with mental illness (Schulze et al., 2003; Watson et al., 2004). Comparing the findings of the present study to those in other countries, the young population in Greece appears to be very distancing towards PwS. Schulze et al. (2003) report that only 6.5% of students (average percentage between the experimental and control group) stated that they would be afraid to talk to a PwS, a rate that reaches as high as 46.75% in our sample. Furthermore, while in Germany, 20.5% of students admitted that they could fall in love with a PwS, in Greece the rate is slightly lower, i.e. 13.2%. Interestingly, while adolescents in Greece express greater desire for social distance from PwS in comparison to their counterparts in Germany, the difference between the two countries is more striking in items concerning superficial encounters with the patient. In particular, the difference in percentages between the two countries with regard to the item Would you be afraid to talk to a PwS? reaches 26.75%. Adolescents high levels of stigmatization against PwS in Greece may be attributed to the Greek origin of the word schizophrenia and the strongly stigmatizing media portrayals of PwS in the country (Economou, Kourea et al., 2005). In Greek society the term schizophrenia is linked to fear and devastation and even mental health professionals are avoiding its use by replacing it with that of psychosis. Therefore, it is not surprising that while most of the adolescents are oblivious to what the word denotes, based on its literal meaning (i.e. split mind), they usually speculate that the term is germane to a split personality or a fragmented mind, both of which are mainly associated with the traits of violence, dangerousness and unpredictability (Economou et al., 2009). Furthermore, adolescents in Greece are continuously exposed to stigmatizing portrayals of PwS in the media, especially on TV and at the cinema. An illustration of this point is the film Texas Chainsaw Massacre, which has been repeatedly broadcast on TV and in the cinema but which in Greece was released as The Schizophrenic Killer with the Chainsaw. The very stigmatizing Greek title capitalized on the association between a schizophrenic patient and a serial killer in lay peoples mind and therefore strengthened the stereotype of dangerousness pertaining to PwS. It is noteworthy that during the anti-stigma intervention when students were asked about their sources of information with regard to severe mental illness, the majority identified TV as

Composite score

Baseline

Post-interven on 12-month follow-up

Figure 1. Differences in social distance composite scores across the three time points of the study.

all items apart from two (PwS hear voices and PwS can be successfully treated outside the hospital, in the community), lending support to the long-term effectiveness of the intervention. Concerning desired social distance from PwS, of the seven items of the section, significant differences between baseline and follow-up measures emerged for only three: being classmates with a PwS, inviting him/her to a party and sharing a room in a school excursion. For the remaining items, the improvement observed at post-intervention was not maintained. For the control group, no significant differences were observed between the pre-intervention and follow-up measures for any item (p > .05). When social distance was analysed on a scale level, a repeated measures ANOVA with post hoc comparisons using the Bonferroni correction revealed a significant difference between the baseline and post-intervention social distance scores (M = 18.36, SD = 2.46 and M = 15.63, SD = 2.67, respectively), indicating a positive short-term effect of the intervention; however, no significant difference was discerned between the baseline and the follow-up scores (follow-up M = 17.96, SD = 2.23), indicating that one year after the intervention, the students returned to their baseline social distance levels (Figure 1). Positive baseline scores and female gender were the only two variables that predicted positive attitudes and lower social distance scores at follow-up (R2 = 5.1%, F = 2.79, p < .05 for beliefs and attitudes composite score and R2 = 20.1%, F = 11.41, p < .001 for social distance composite score).

Discussion
The findings of the present study lend support to the imperative need for developing effective anti-stigma interventions targeting children and adolescents. Prior to receiving any intervention, students were found to hold stereotypical beliefs and rejecting attitudes towards PwS. The majority of them espoused the belief that PwS are dangerous, cannot work, speak to themselves or shout in city streets, suffer from split personality and constitute a public nuisance. A similar pattern of results has been recorded in the adult

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550 their primary source and spontaneously referred to The Schizophrenic Killer with the Chainsaw. Compared to the literature that points towards gender and familiarity with mental illness as factors that play a prominent role in stigma endorsement, the present study found no gender effect for baseline measures but a significant impact of personal experience with mental illness. The influence of gender on beliefs and attitudes to people with mental illness has yielded conflicting results, with some studies reporting that girls are more positive towards the patients (Ng & Chan, 2002; Williams & Pow, 2007) and some others failing to find a significant difference (Schulze et al., 2003). Similarly, familiarity with mental illness has been found to be associated with both more positive (Pinfold et al., 2003) and more negative attitudes (Corrigan et al., 2005). An interesting finding of the study was that only female gender and baseline scores could predict follow-up scores. While this is in line with the findings of an earlier study (Pinfold et al., 2003), it is surprising that personal experience with mental illness had a non-significant contribution to the model. A possible explanation for this is the diversity in the intensity of familiarity, which can vary from a person watching TV portrayals of mental illness to having a distant or a close relative suffering from a psychiatric disorder (Corrigan, Backs-Edwards, Green, Lickey-Diwan, & Penn, 2001). It is therefore plausible that the educational intervention increased students familiarity with mental illness and as a result of this, the differences that emerged at baseline were compensated for at follow-up. In terms of the effectiveness of the educational intervention in modifying beliefs, attitudes and desired social distance from PwS, immediately upon its completion and at a 12-month follow-up, the results that emerge support the existing literature. In line with other studies (Ng & Chan, 2002; Schulze et al., 2003; Watson et al., 2004), the educational intervention was found to have a positive impact as indicated by an improvement in attitudes and a remarkable decrease in the frequency of stereotypical beliefs and in the degree of desired social distance. With regard to the followup results, the picture is more diverse. On the one hand, significant improvements in adolescents beliefs and attitudes after the intervention were largely maintained 12 months after its completion. On the other, the improvement recorded on the social distance items upon completion of the intervention was not maintained at follow-up, where students almost returned to their baseline answers. In line with Pinfold et al. (2003), it appears that social distance is more resistant to change than other measures of stigmatization and possibly necessitates a different approach for targeting it. The intervention of the present study was brief and lacked a personal contact component. As a result, an anti-stigma intervention aiming at decreasing adolescents desired social distance from PwS should consider involving patients and allow for an interaction between them and the adolescents. Furthermore, this intervention should be longer and constantly delivered throughout the developmental period of

International Journal of Social Psychiatry 58(5) stereotype formation and consolidation. In this way, even if adolescents are exposed to stigmatizing portrayals of people with mental illness, in the media for example, their personal contact with a number of PwS in the classroom coupled with the appropriate education will enable them to stand critically towards the vehicles that perpetuate the stigma attached to mental illness. Health promotion programmes, like those implemented at the participating schools, should become an integral part of the high school curriculum and should be delivered throughout school years.

Limitations
The major shortcoming of the present study was its inability to extrapolate its findings to a representative sample of adolescents throughout the country. The sample was restricted to urban areas and only schools with a health promotion programme in their curriculum took part. Given that the preponderance of psychiatric stigma in Greek urban areas has been found to be lower compared to rural areas (Economou et al., 2009) and that students from schools with a health promotion programme in their curriculum are possibly more tuned and sensitized to issues of health, stigma endorsement might have been stronger if a more diverse sample was attained. This assumption is further supported by the opposition expressed by many schools to deliver any kind of intervention related to severe mental illness to their students. In Greece, talking about severe mental illness, and especially about schizophrenia, to students is still a major taboo and demonstrates further how entrenched psychiatric stigma is in the Greek culture. Therefore, a future study aiming at broadening its recruitment scope would cast light on adolescents degree of stigma endorsement and subsequently on the potential of an anti-stigma intervention to fight it. Acknowledgements
The authors would like to express their gratitude to Dimitris Kolostoumpis, psychiatrist, and Maria Charitsi, psychologist, University Mental Health Research Institute, for their valuable contribution to the implementation of the study, as well as to Anastassios Stalikas, Professor of Psychiatry, Panteion University, for his contribution to the analysis of the results.

Funding
This research was conducted within the framework of the Greek Programme against Stigma and Discrimination because of Schizophrenia, whose major sponsor was the National Bank of Greece.

References
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