Anti-stigma training and positive changes in mental illness stigma outcomes in medical students in ten countries: a mediation analysis on pathways via empathy development and anxiety reduction
Authors: Potts Laura C. , Bakolis Ioannis , Deb Tanya , Lempp Heidi , Vince Tushar , Benbow Yasmin , Waugh William , Kim San , Raza Syed , Henderson Claire ,   The INDIGO READ Study Group, Thornicroft Graham , Ando Shuntaro , Kondo Shinsuke , Ichihashi Kayo , Kasai Kiyoto , Yamaguchi Sosei , Matsunaga Asami , Ojio Yasutaka , Ogawa Makoto , Fujii Chiyo , Candelas Andrea , Martín Laura , Jiménez Andrea , Castañeda Cristina , Hernández Cecilia , de la Higuera Jesús , Muñoz-Negro José Eduardo , Sola Mercedes , García Rocío , Gota José Miguel , Mula Juan Francisco , López Ana , Oria Amadeo , Cervilla Jorge A. , Bono Aguila , Franco Dolores , Gómez Jaime , Jiménez Carmen , Dorado Remedios , Ingunza Evelio , Márquez Irene , de la Vega Diego , Gª-Cubillana Pablo , Ouali Uta , Jouini Lamia , Zgueb Yosra , Nacef Fethi , Campbell Megan , Stein Dan , Harangozo Judit , Acs Andrea , Bulyáki Tünde , Szabó Gyöngyi , Ojo Tunde Masseyferguson , Ogunwale A. , Sowunmi A. O. , Awhangansi S. S. , Ogundapo Deji , Sodiya O. T. , Fadipe Babatunde , Olagunju Andrew T. , Erinfolami Adebayo R. , Ogunnubi Peter O. , Tomás Catarina Cardoso , Janoušková Miroslava , Krupchanka Dzmitry , Bacle Simon Vasseur , Colliez Antoine , Sebbane Deborah , Mengin Amaury C. , Vidailhet Pierre , Cazals Cyril , Fiorillo Andrea , Sampogna Gaia , Savorani Micaela , Del Vecchio Valeria , Luciano Mario , Borriello Giuseppina , Pocai Benedetta , Guimaraes Patricia Neves , Caldeira Antônio Prates , de Avelar Pedro Paulo Narciso 
Published: April 2022

Abstract
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.