ARTICLES
Public Stigma in China Associated With Schizophrenia,
Depression, Attenuated Psychosis Syndrome, and
Psychosis-Like Experiences
Edwin Ho-Ming Lee, M.B.Ch.B., M.Sc., Christy Lai-Ming Hui, Ph.D., Elaine Yee-Ning Ching, M.Sc., Jingxia Lin, Ph.D.,
Wing-Chung Chang, M.B.Ch.B., Sherry Kit-Wa Chan, M.B.B.S., M.Phil., Eric Yu-Hai Chen, M.D.
Objective: Attenuated psychosis syndrome (APS) has re-
cently been included in the appendix of DSM-5 as a condi-
tion for further study. This study compared public stigma
associated with four mental health conditions among study
participants in Hong Kong.
Methods: The cross-sectional study involved 204 participants
(154 members of the general public general public and 50
health care professionals) recruited through a public awareness
campaign and the e-mail network of the University of
Hong Kong. Participants read four vignettes describing per-
sons with schizophrenia, depression, APS, or psychosis-like
experiences. For each vignette, they used a scale to rate their
level of stigma in seven domains: social distance, traditional
prejudice, exclusionary sentiments, negative affect, perceptions
of dangerousness, treatment carryover, and disclosure carry-
over. Analyses compared ratings within and across vignettes.
Among people with mental illness, stigma has adverse effects
in multiple domains—from detection to treatment and re-
covery (1–3). Antistigma and public awareness programs
have been conducted to minimize the impact of public
stigma on patients and their families, but the effectiveness of
such programs has been questioned (4,5). With the recent
emphasis on detecting and treating individuals in the pro-
dromal phase of psychosis, concerns have been raised about
whether stigma would spread to this at-risk population.
Attenuated psychosis syndrome (APS), which is character-
ized by psychosis-like symptoms that are below the
threshold for full psychosis, is included in DSM-5 under
“conditions for further study.” Scholars continue to debate
whether the condition should be classified as a separate di-
agnostic entity and whether the risk of developing full-
blown psychosis and the level of stigma associated with APS
are as substantial as they were thought to be (6,7).
Schizophrenia has been viewed as a more stigmatized
mental illness than depression (8–10). Many people believe
that schizophrenia is a brain disorder and that it is harder
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Results: Schizophrenia received the highest public stigma
ratings, followed by APS, depression, and psychosis-like
experiences. Total stigma scores were higher for the general
public than for health care professionals. Public stigma as-
sociated with APS was similar to that associated with de-
pression. Ratings of treatment carryover indicated that
participants believed that being known to have received
treatment for APS or depression would have lasting
consequences.
Conclusions: Stigma should be considered in the develop-
ment of mental health services and research in China, par-
ticularly in regard to people with schizophrenia and those at
risk of psychosis.
Psychiatric Services in Advance (doi: 10.1176/appi.ps.201500156)
to control, more unpredictable, and more dangerous
than depression and less likely to be treated (9,11,12). In
contrast, many view depression as easier to control than
schizophrenia, more predictable, less dangerous, and more
treatable; people are less likely to want to maintain social
distance from individuals with depression (13). Severity of
symptoms and deviation from normal behavior may also
affect stigma (14–16).
These explanations of the effects of stigma may apply
only when the illness is clearly understood. In the case of
APS, people may not fully understand the condition, which
may affect their attitude toward the affected individual (17).
The symptoms of APS and schizophrenia are similar. Even
though APS symptoms are less severe, people might base
their understanding of APS on their knowledge of psychosis.
This study compared public stigma associated with APS and
with schizophrenia, depression, and psychosis-like experi-
ences. We hypothesized that public stigma associated with
APS is less than that associated with schizophrenia and
similar to that associated with depression and that public
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MENTAL ILLNESSES AND PUBLIC STIGMA IN CHINA
stigma is lower among individuals with more education and
previous contact with persons with mental disorders.
METHODS
Study Design
This cross-sectional study of public stigma used a vignette
methodology. A total of 204 Chinese participants were
recruited through a public awareness campaign and through
the e-mail network of the University of Hong Kong. Indi-
viduals age 18 and older who had never had a diagnosis of
or treatment for a mental disorder and who consented to
participate were included. The study was approved by
the Institutional Review Board of the University of Hong
Kong/Hospital Authority Hong Kong West Cluster and
performed in accordance with ethical standards of the 1964
Declaration of Helsinki and its later amendments. Basic
demographic information, including age, gender, current
occupation, and education level, was collected. Previous
contact with persons with mental illness was also noted on
the basis of questions adapted from Alexander and Link (18).
Participants read four vignettes describing individuals with
APS, schizophrenia, depression, or psychosis-like experiences
and responded online. They used a seven-domain stigma scale
(SDSS) to rate their level of public stigma associated with each
of the four individuals in the vignettes. [The four vignettes are
included in an online supplement to this article.]
Measures
Each of the vignettes objectively described symptoms and
functioning of the person with the disorder. The schizophrenia
and depression vignettes stated the diagnosis and were pre-
viously used in study by Pescosolido and colleagues (19). The APS
vignette described the likelihood of transition to psychosis as
follows: “People at high risk of psychosis have not yet developed
a full psychotic disorder but have some symptoms that might
lead to a future psychotic disorder. However, only 35% of these
individuals will go on to exhibit psychosis within 2.5 years of
identification” (20). The vignette on psychosis-like experiences
described a person with no psychiatric diagnosis and normal
functioning who experienced transient psychotic symptoms.
English versions of the Chinese vignettes were back-translated
by a professional translator and proved to be satisfactory.
The SDSS is a 27-item questionnaire about public stigma
adopted from Pescosolido and colleagues (19). The scale
measures seven major domains of public stigma, including
social distance, traditional prejudice, exclusionary senti-
ments, negative affect, perceptions of dangerousness, treat-
ment carryover, and disclosure carryover. Social distance
refers to reluctance to interact with members of a group.
Traditional prejudice refers to adherence to the belief that
all members of a group are categorically inferior to others.
Exclusionary sentiment refers to the willingness to exclude
people from a group from the full benefits of citizenship.
Negative affect refers to public views that people from a group
are difficult to interact with. Perception of dangerousness is
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about the fear that persons from a group represent a threat of
violence to self or others. Treatment carryover is the belief
that being known to have received mental health care carries
long-lasting consequences. Disclosure spillover refers to the
negative consequences of revealing one’s mental illness. The
SDSS uses a 4-point Likert scale (1, strongly agree; 2, agree; 3,
disagree; and 4, strongly disagree) to measure agreement with
statements about each vignette. Each domain score was cal-
culated by summing responses from the relevant items and
dividing by the total number of items in the domain. Scores
above the midpoint (2.0) indicated a stigmatizing attitude,
with higher scores indicating more severe public stigma.
Statistical Analyses
Statistical analyses were conducted with SPSS, version 20.0.
The Kolmogorov-Smirnov test was used to test for normality
of noncategorical variables, and Wilcoxon signed-rank tests
were used to examine differences in scores between pairs of
vignettes. Kruskal-Wallis or Mann-Whitney tests examined
differences in scores between demographic variables.
RESULTS
Demographic Characteristics
As shown in Table 1, 204 participants (154 from the general
public and 50 health care professionals) completed the
questionnaires. The mean age of the 204 participants was
27.3. Seventy percent were female, and 64% had un-
dergraduate or postgraduate degrees. Most participants did
not have relatives or close friends who had been hospitalized
in a psychiatric unit. However, about half (43%) had worked
or volunteered in mental health services.
Domain Scores Across Vignettes
As shown in Table 2, total stigma scores were highest for
schizophrenia, followed by APS, depression, and psychosis-
like experiences. For both schizophrenia and psychosis-like
experiences, total stigma scores and all domain scores dif-
fered significantly (p,.001) from scores for the other vi-
gnettes. For APS and depression, only the domain score for
treatment carryover differed significantly.
For APS and depression, the order of domains as ranked by
score was similar; the domain with the highest score for both
vignettes was disclosure spillover, followed by perception of
dangerousness, and treatment carryover. For APS, the two
domains with the next-highest scores were social distance
and traditional prejudice, followed by negative affect and
exclusionary sentiments. In contrast, for depression, the two
domains with the next-highest scores were traditional prej-
udice and social distance, also followed by negative affect and
exclusionary sentiments. However, there was no significant
difference between domain rankings for depression. For
schizophrenia, domain rankings were as follows (from highest to
lowest score): disclosure spillover, perception of dangerousness,
treatment carryover, social distance, negative affect, traditional
prejudice, and exclusionary sentiments. Significant differences
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TABLE 1. Characteristics of 204 participants in a vignette study vignette, total scores of participants from the general public were
of public stigma higher than scores of health care professionals (Z=23.0, p,.01);
Characteristic N % the scores for these two groups did not differ significantly for
Participant group any other vignette. For the APS vignette, some domain scores
Public 154 76 (data not shown) were also significantly higher for the public
Health care professional 50 25 group than for the professional group: social distance (Z=22.86,
Age (M6SD) 27.3610.5 p,.01), negative affect (Z=23.98, p,.001), and perceptions of
Gender dangerousness (Z=22.39, p,.05). No significant differences
Male 62 30
between rankings were found by gender and age for any vignette.
Female 142 70
Significant differences in total stigma scores were found
Education level
Primary 1 1
by education level for both the APS and the schizophrenia
Secondary 18 9 vignettes. For the APS vignette, participants who had a high
Diploma 53 26 school diploma had significantly higher scores than partic-
Undergraduate degree 76 37 ipants in the other education-level groups (x2=12.8, df=4,
Postgraduate degree 55 27 p,.05). For the APS vignette, scores in two domains (data
Missing 1 1
not shown) were also significantly higher for those with a
First-degree relatives hospitalized
high school diploma than for those in the other education-
Self 3 2
Parent 6 3 level groups: traditional prejudice (x2=11.7, df=4, p,.05) and
Children 1 1 negative affect (x2=13.0, df=4, p,.05). For the schizophrenia
Sibling 4 2 vignette, participants without a high school diploma (sec-
No 188 92 ondary level) had significantly higher scores than those in
Missing 2 1
the other education-level groups on one domain: treatment
Other relative hospitalized carryover (x2=11.1, df=4, p,.05).
Yes 22 11
No 180 88
For all vignettes, total stigma scores of participants who
Missing 2 1 reported working or volunteering in mental health services
Close friend or spouse hospitalized were significantly lower than total scores of participants
Close friend 16 8 who reported no such experiences (Table 3). For the APS
No 186 91 vignette, not only did the total stigma score differ between
Missing 2 1 these groups (x2=24.1, df=2, p,.001), but the scores on five
Worked or volunteered in mental health services domains (data not shown) also differed: social distance
Worked 50 25 (x2=25.7, df=2, p,.001), traditional prejudice (x2=10.2, df=2,
Volunteered 37 18
No 121 59
p,.01), negative affect (x2=26.0, df=2, p,.001), perception
Missing 29 14 of dangerousness (x2=13.2, df=2, p,.001), and treatment
Visited psychiatric hospital for purpose other carryover (x2=8.6, df=2, p,.01). For the schizophrenia vi-
than treatment gnette, scores between the general public and health care
Yes 74 36 professionals differed for two domains: negative affect
No 130 64 (x2=8.0, df=2, p,.05) and treatment carryover (x2=9.8, df=2,
Saw someone in public who seemed mentally ill p,.01). For the depression vignette, scores between the two
Often 18 9 groups differed only for the domain of treatment carryover
Sometimes 144 71
Almost never 36 18
(x2=8.9, df=2, p,.05). For the psychosis-like experiences
Never 5 3 vignette, scores between the two groups differed for two
Missing 1 1 domains: exclusionary sentiments (x2=8.5, df=2, p,.05) and
negative affect (x2=8.6, df=2, p,.01).
Finally, for the APS vignette, participants who reported
with other vignettes were noted for social distance (Z=22.00, encountering someone in public who appeared to be mentally
p,.05) and negative affect (Z=21.97, p,.05). For psychosis- ill either often or sometimes had higher scores on two domains
like experiences, domain rankings were as follows: disclosure than those who reported almost never having such encounters
spillover, treatment carryover, traditional prejudice, social dis- (data not shown): exclusionary sentiments (x2=1.0, df=3, p,.05)
tance, dangerousness, exclusionary sentiments. Significant and negative affect (x2=15.3, df=3, p,.01).
differences with other vignettes were noted for treatment
carryover (Z=22.09, p,.05), and exclusionary sentiments
DISCUSSION
(Z=22.11, p,.05).
In this cross-sectional study involving 204 participants, we
Total Scores Across Vignettes by Characteristic found that the stigma scores of the general public were
Table 3 presents total public stigma scores for each vignette highest for schizophrenia, followed by APS, depression, and
by demographic and other characteristics. For the APS psychosis-like experiences. Of note, stigma scores indicated

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MENTAL ILLNESSES AND PUBLIC STIGMA IN CHINA

TABLE 2. Scores of 204 participants on seven domains of public stigma, by mental health or not they were a health care
conditiona professional, and whether they
Psychosis-like worked or volunteered in men-
Schizophrenia APS Depression experiences tal health services.
Total score and domain M SD M SD M SD M SD Studying public stigma as-
Total score 2.45* .43 2.22 .36 2.10 .38 1.79* .44 sociated with various mental
Domain health conditions is important
Social distance 2.53* .58 2.24 .49 2.08 .51 1.77* .54 because stigma can affect help-
Traditional prejudice 2.31* .44 2.14 .45 2.09 .45 1.81* .59
seeking behavior and recovery.
Exclusionary sentiments 2.20* .95 1.97 .48 1.96 .52 1.64* .48
Negative affect 2.42* .70 2.02 .57 2.01 .57 1.64* .52 Public stigma associated with
Perceptions of dangerousness 2.56* .63 2.38 .68 2.31 .55 1.76* .62 APS was found to be weaker
Treatment carryover 2.56* .60 2.31* .90 2.15* .64 1.86* .71 than that associated with
Disclosure spillover 2.61* .45 2.52 .44 2.34 .51 2.04* .58 schizophrenia, whereas stigma
a
APS, attenuated psychosis syndrome. Possible scores range from 1 to 4, with higher scores indicating more severe associated with APS and de-
stigma. pression was similar. This
*p,.001, for difference with scores of all other vignettes
finding suggests that sub-
stantial public stigma is asso-
that APS and depression were perceived similarly by study ciated with APS; being known to have received treatment for
participants; however, significantly higher scores for APS on APS was perceived as having lasting consequences. The
the domain of treatment carryover indicated that partici- findings also suggest potential stigma reduction strategies;
pants believed that being known to have received treatment for example, the public should be informed about the high
for APS would have more lasting consequences than treatment remission rate among individuals who experience psy-
for depression. Demographic and other characteristics chotic symptoms and the potential for complete recovery.
appeared to have affected stigma scores for the four mental A positive finding is that even though symptoms of APS
health conditions, with the largest effects seen for APS. and schizophrenia have similar presentations, stigma scores
Characteristics that affected stigma included participants’ were lower for APS. This finding may be related to un-
education level, the frequency with which they encountered certainty about whether all individuals with APS transition
in public someone who appeared to be mentally ill, whether to a full-blown psychotic disorder.
Ranking by score on stigma
domains for schizophrenia dif-
TABLE 3. Total public stigma scores of 204 participants, by mental health condition and participant fered more than for the other
characteristica conditions. For schizophrenia,
Psychosis-like higher scores were given to
APS Schizophrenia Depression experiences “immediate emotion-focused”
Characteristic M SD M SD M SD M SD domains, such as perceptions
Participant group
of dangerousness, negative
Public 2.27 .09 2.41 .11 2.17 .10 1.86 .10 affect, and social distance, and
Professional 2.14 .06 2.41 .12 2.11 .07 1.86 .10 scores for “higher-order social
Gender values,” such as traditional
Male 2.19 .08 2.47 .07 2.14 .09 1.92 .14 prejudice, were lower (19,21).
Female 2.22 .07 2.39 .11 2.14 .08 1.83 .08 This finding may result from
Education level differences in how the public
Secondary 2.22 .15 2.41 .04 2.26 .15 2.06 .17 perceives the role of biopsy-
Diploma 2.49 .09 2.49 .05 2.38 .10 2.17 .11
Undergraduate degree 2.17 .07 2.35 .13 2.05 .09 1.74 .09
chosocial factors in these
Postgraduate degree 2.19 .10 2.49 .11 2.18 .10 1.96 .15 illnesses. The public may
Worked or volunteered in mental view biopsychosocial factors
health services as playing a larger role in
Work 1.95 .09 2.17 .21 1.94 .11 1.58 .12 APS and depression, com-
Volunteer 2.23 .12 2.43 .23 2.14 .18 1.96 .20 pared with schizophrenia (22).
No 2.32 .07 2.52 .07 2.23 .08 1.97 .09
In addition, the public may
Saw someone in public who seemed view the individual affected by
mentally ill
Often 2.20 .17 2.83 .02 1.91 .31 1.74 .41
APS or depression as being
Sometimes 2.24 .06 2.48 .07 2.19 .07 1.87 .08 more responsible for having
Almost never 2.08 .13 2.04 .30 1.97 .18 1.85 .17 the illness, as reflected in the
a
APS, attenuated psychosis syndrome. Possible scores range from 1 to 4, with higher scores indicating more severe scores for traditional preju-
stigma. dice and negative affect.

4 ps.psychiatryonline.org PS in Advance

This study had several limitations. First, the study did
not assess self-stigma. Second, there was no qualitative in-
vestigation of participants’ stigma perceptions, which may
have provided additional insight into beliefs held by the
general public. Third, the concept of APS is relatively new,
and we did not assess public knowledge about APS. Although
we provided a working definition of APS for participants,
their stigma ratings may also have depended on their pre-
vious knowledge or experiences. Fourth, the participants
may not have been representative of the larger population.
Fifth, although the vignettes were reviewed by local expe-
rienced psychiatrists for face validity before use, the validity
had not been studied in Chinese culture. Sixth, the 4-point
scale may not have been able to distinguish between APS and
depression groups. Finally, our study was limited to the in-
vestigation of public stigma in the Chinese culture, and
generalization to Western cultures may not be feasible.
Future studies of APS in countries with different beliefs and
cultures are warranted.
CONCLUSIONS
This study not only expands literature on public stigma as-
sociated with mental illnesses but also contributes to future
considerations about whether APS should be a clinical di-
agnostic category. Understanding how the public perceives
APS can inform future research and development of clinical
services. Stigma reduction programs should consider ways
to increase the public’s contact with persons with mental
illness. To alter negative views of mental illness, such pro-
grams should provide accurate information about the dan-
gerousness of persons with mental illness and about positive
treatment outcomes.
AUTHOR AND ARTICLE INFORMATION
The authors are with the Department of Psychiatry, University of
Hong Kong, China (e-mail: edwinlhm@hku.hk).
The authors report no financial relationships with commercial interests.
Received April 22, 2015; revision received September 15, 2015; accepted
October 26, 2015; published online March 15, 2016.
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