While schizophrenia appears to be widely misunderstood and associated with stigma, the results of a global project first tested in Canada shows improved knowledge of and attitudes toward this illness, especially among teenagers.

The World Psychiatric Association (WPA) developed its "Open the Doors" campaign in 1996 to reduce stigma and discrimination against people with schizophrenia. The action plan outlines strategies taken from successful public health campaigns, such as using mass communication techniques and technology and involving patients.

To determine the impact of the action plan on a given population, the WPA international steering committee for the campaign selected the city of Calgary in western Canada in 1997 as the test site.

Heather Stuart, Ph.D., an epidemiologist with the University of Calgary during the first 12 months of the 18-month project, told Psychiatric News, "We were chosen because we had the research capacity to get a pilot study done in an aggressive timeline and had worked extensively with the World Health Organization and the WPA before. Also, our proposal included a rural area, which was important because much of the world’s population lives in rural areas."

Calgary, which is in the province of Alberta, has a population of 900,000, and rural Drumheller, near Calgary, has a population of 5,000, according to Julio Arboleda-Florez, M.D., chair of the Calgary project during its first 12 months. He is now the project’s national director and a professor and head of psychiatry at Queens University in Ontario, and Stuart is a project consultant and associate professor of community health and epidemiology at Queens.

The project received funding from Eli Lilly and Company and the Provincial Mental Health Board, according to Arboleda-Florez.

The groups chosen for interventions by the local action committee were teenagers (grades nine and 11), the general public, health professionals, and people in positions of influence in the community, including clergy, journalists, and business leaders, said Stuart.

Teens showed significant improvements in their knowledge of schizophrenia and attitudes toward people with the illness. Stuart attributed this to patients and their relatives’ visiting schools and talking to students, performing plays, and sponsoring a new essay competition on schizophrenia.

Research has shown that "having an emotional connection with patients is very effective in reducing stigma," said Stuart.

This was also true of human-interest stories written by a journalist at the Calgary Herald, who won a national award from the Friends of Schizophrenia. The stories, press events, and 30-second radio spots combined were successful in making people more aware of schizophrenia, said Stuart.

Each target group’s knowledge and attitudes toward people with schizophrenia was assessed at baseline to refine outreach interventions and after the outreach to measure their effectiveness.

Patients were asked by the committee to identify discriminatory practices in the community.

"Ironically, they felt the most stigmatized by the medical community, in particular by emergency room staff," said Arboleda-Florez. "Among their complaints were that they were not treated with respect or interviewed in private settings."

Emergency room personnel were surveyed regarding privacy, policies on patients’ rights and the use of restraints, staff training in mental health and crisis management, waiting times, and patient satisfaction with services, according to Stuart.

The results showed that some changes needed to be made. Emergency room staff in Drumheller are now regularly trained in mental health issues, and a psychiatric nurse was hired in the emergency room there. A private space for interviewing psychiatric patients has been created in an emergency room in Calgary, according to a report on the pilot project.

Changes are also being made nationally. The Canadian Council on Health Services Accreditation accepted the committee’s emergency room guidelines for treating psychiatric patients, which will be implemented by hospitals throughout Canada, said Stuart.

Arboleda-Florez and Stuart discussed the lessons learned from the pilot project with Psychiatric News at the annual meeting of the Canadian Psychiatric Association in Victoria last month.

"Our decision to concentrate our efforts on specific groups was effective and affordable. Also, we set realistic goals, such as a 10 percent increase in knowledge and attitudes for students," said Stuart.

"We also found that it is much easier to reach the targeted group if there is an effective representative on the action committee," said Arboleda-Florez.

For example, the health teacher on the local action committee helped introduce a well-researched teaching guide on schizophrenia to her colleagues. "This replaced the outdated health curriculum that contained misperceptions and myths about schizophrenia," said Stuart.

Other action committee members were consumers and representatives of consumer organizations, health care professionals in academia and the community, a journalist, and representatives from the provincial government, according to Arboleda-Florez. However, the outreach to business people and clergy was hindered by their not being represented on the committee, said Stuart.

Several efforts begun during the pilot program have continued, including the outreach to teens, congregations, and teachers.

The results of the pilot program and materials were shared with the federal department of health with the goal of developing a national antistigma program. The department staff have indicated they are interested, said Stuart.

"We have also shared our results, lessons learned, and materials with the WPA. Based on our success, the WPA has since 1998 approved antistigma campaign proposals from Austria, Spain, China, Egypt, Australia, Germany, Greece, India, Italy, and the United States."