To the Editor: Stigma associated with mental illness may commonly be encountered in the media (1), among the public (2), and in professional groups such as physicians (3). We therefore read with great interest the article by Korszun et al., which explored medical students’ attitudes toward mental illness (4). The study is commendable and innovative in two regards, namely, the assessment of attitudinal change with years of medical school completed and also the exploration of the religious and ethnic backgrounds of the responders. Also, although the percentage response rate could not be determined because of ethical limitations, the quantitatively large response of 760 medical students is certainly helpful in determining attitudinal differences.

However, we noted, with some concern, several methodological limitations that we believe are important to highlight. The article used a modified version of the Medical Condition Regard Scale (MCRS) as a tool to compare medical student attitudes toward several medical and psychiatric presentations. We were somewhat surprised that the main medical comparator to the psychiatric conditions was “pneumococcal pneumonia.” Pneumococcal pneumonia is recognized as the most common cause of community-acquired pneumonia (5). In the majority of cases, outpatient treatment with a short course of antibiotics will lead to disease resolution (5). This condition was compared with several presentations that were suggestive of severe psychiatric disorders, including “long-standing auditory hallucinations and paranoid delusions” and “depression with intermittent suicidal thoughts.” Severe psychiatric disorders differ from pneumococcal pneumonia as they are characteristically chronic in nature, following a relapsing–remitting pattern, and are disorders where symptom-reduction is more often the goal, rather than complete cure. Furthermore, the adjectives used in describing these psychiatric conditions, such as “long-standing” and with “intermittent suicidal thoughts” may suggest they are particularly severe or complex. The description of these active and poorly-controlled symptoms may also suggest that the underlying psychiatric disorder is poorly treated or treatment-resistant.

In this context, we believe that medical students should be presented with chronic medical conditions, which better mirror psychiatric disorders. Interestingly, the original study describing the MCRS incorporated a chronic medical condition, namely “emphysema from smoking” (6). Emphysema from smoking had mean MCRS scores suggestive of greater stigma than almost all of the psychiatric conditions that the original study investigated (6). The mean MCRS score of “emphysema with smoking” in the original study was also considerably lower than the MCRS scores of all the psychiatric presentations in all medical student classes in the current study.

Stigma toward mental illness is commonplace, and, unfortunately, we have limited resources to overcome it. Comparing conditions with discordant disease characteristics may open the door to biases based on disease course, chronicity, and outcome. It is important to recognize and attempt to minimize such biases, as research findings in this field may directly affect resource allocation and future attempts in combating stigma.