To the Editor: Drs. Vahabzadeh and Schwartz make a valid point that certain conclusions cannot be drawn by making a comparison between an acute medical condition, such as pneumococcal pneumonia, and chronic mental health disorders. They are also correct that the full Medical Condition Regard Scale (MCRS) included smoking-related emphysema as one of the medical conditions. However, a comparison between pneumococcal pneumonia and psychiatric conditions was not the focus of our paper. We were interested in exploring how attitudes to psychiatric conditions and medically unexplained physical symptoms may differ among different groups of medical students, for example, by age, gender, ethnicity, and stage of studies. We included pneumococcal pneumonia because it is a disorder with an obvious, external etiology (that even first-year students would recognize as such) in order to act as a “positive control.”

Although our results suggest that there has been progress in reducing stigmatizing attitudes to mental health disorders such as depression, what is more important for us as educators, is that we do not seem to be changing the attitudes of students, who persist in holding stigmatizing attitudes. Levels of regard toward patients with mental health conditions remain similar in final-year medical students, as compared with those in first years of the course. Furthermore, there are differences in attitudes between different groups, for example, less tolerance of psychotic symptoms by South Asian students, or higher regard for those with depression in students who have personal experience of mental health disorders. However, negative attitudes to medically unexplained symptoms remain highest and appear to deteriorate over the course of medical studies, and this matter needs to be urgently addressed. Chronic conditions that are not easily remedied may attract more stigmatizing attitudes, reflecting frustration, and perhaps an expectation that Medicine should yield more immediate and satisfying patient recovery.

We would agree with Drs. Vahabzadeh and Schwartz that there would probably also be a high degree of stigma associated with smoking-related diseases, but, although this is an interesting point, it was not the one being investigated in our study. Stigma appears to be associated not only with chronicity and failure to respond to treatment, but also with moral judgments about entitlement to treatment for conditions such as obesity, smoking, and, perhaps, depression; where these attitudes are widespread this can also lead to self-stigma. Stigmatizing attitudes that are related to cultural beliefs and values influence both moral judgments and self-stigma, and these need to be taken into account in medical students’ education.