1. T o achieve an early intervention in psychiatric illnesses, reducing public stigma is thought to be of great importance. To reduce public stigma, it is important to have a precise knowledge of the nature of that stigma. Although some investigations about stigmas in Japan have been undertaken, most of them omitted the opinions of those who did not cooperate with the research group, or those who might stigmatize psychiatry. The results might therefore not reflect the state of public stigma. In order to include both those who stigmatize psychiatry to a great degree and to a lesser a degree, we prepared a freely accessible online questionnaire. T o achieve an early intervention in psychiatric illnesses, reducing public stigma is thought to be of great importance. To reduce public stigma, it is important to have a precise knowledge of the nature of that stigma. Although some investigations about stigmas in Japan have been undertaken, most of them omitted the opinions of those who did not cooperate with the research group, or those who might stigmatize psychiatry. The results might therefore not reflect the state of public stigma. In order to include both those who stigmatize psychiatry to a great degree and to a lesser a degree, we prepared a freely accessible online questionnaire. We declare no conflict of interest directly relevant to the contents of this presentation. Disclosure of research funding: The Government of Shiga Prefecture, Japan National Mutual Insurance Federation of Agricultural Cooperatives Shionogi & Co., Ltd Otsuka Pharmaceutical Co., Ltd Shiga University of Medical Science The Shiga Medical Science Association for International Cooperation In March 2014, a freely accessible online questionnaire in Japanese was made available. It was publicized on bulletin boards and social networking services, such as Facebook TM. The survey was completed in October, 2014. The study was performed without any information provided about the research group. To prevent false or double responses by respondents, we asked respondents their email address and sent them a thank-you mail. After confirming receipt of the mail, we registered them as subjects. We asked participants basic information: age, sex, job and yearly income. We assessed their mental health using the General Health Questionnaire- 12 (GHQ-12). The subject's level of stigmatization was assessed using the Devaluation-Discrimination Scale (DDS). The questionnaire covered both their families' experiences of treatment by mental health services (MHS) and how they conceived of MHS. Our investigation was approved by the ethical review board of our university (25-220). We secured ethical security by the following methods: 1. We did not press respondents who doubted the security of the survey to answer the questionnaire. 2. We explained beforehand how the personal data we obtained from the survey would be used. 3. We declared to the subjects that we would never use the personal data for any purpose not stated in the thank-you letter. There were 969 accesses counted to the survey website. 409 people were registered as subjects. The basic attributes of the subjects are shown in Table 1. To factor in predictors of DDS, we did a multiple regression analysis with subjects' basic attributes, experiences of treatment at MHS, GHQ and hostility to MHS as explanation variables. (Table 2) Experience of treatment at MHS and hostility to MHS significantly correlated with DDS. The mean DDS for those with and without treatment at MHS was 35.6 (SD=6.84, median=36.0) and 32.5 (SD=6.04, median=33.0), respectively. DDS with treatment at MHS was significantly higher than without consultation. (Fig. 1) The mean DDS for those who were satisfied and unsatisfied with their treatment was 33.9 (SD=7.06, median=35.0) and 37.1 (SD=6.30, median=37.0). The number of DDS who were unsatisfied with their treatment was significantly higher than of satisfied patients. (Fig. 2) The number of the subjects who showed hostility to MHS was 223. To factor in predictors of such an attitude in patients, N = 196, we did a multiple logistic regression analysis: having hostility as a purpose variable and their basic attributes, experiences of treatment, GHQ and DDS as explanation variables. (Table 3) Dissatisfaction with their treatment significantly correlated with hostility. To factor in predictors of such an attitude in those who were not patients, N = 213, we did a multiple logistic regression analysis: their basic attributes, families' experiences of treatment at MHS, GHQ and DDS as explanation variables. (Table 4) Dissatisfaction with their families' treatment and DDS significantly correlated with having hostility. The number of subjects whose GHQ-12 score exceeded 2 was 282, and 150 of them were not treated at MHS. 85 of the 150 subjects had hostility to MHS. To factor in predictors of hostility of the 150 subjects, we did a multiple logistic regression analysis: their basic attributes, families' experiences and satisfaction with treatment, GHQ and DDS as explanation variables.(Table 5) DDS significantly correlated with their having hostility, and their families' experiences and satisfaction did not significantly correlate with hostility to MHS. Table 1. Basic attributes of subjects (N=409) Age Mean=39.7, SD=10.5, Median=39.0 Sex Male=214, Female=195 Job Multiple answers allowed Mental Health Services=60 Other Health Services=21 Students=16 Public employees=15 Other regular employment staff=144 Irregular employment staff=86 Unemployed=102 Yearly income <1,000,000 yen=106 1,000,000<, <5,000,000 yen=197 5,000,000<, <10,000,000 yen=74 10,000,000<=32 Experience of treatment at MHS Themselves=196 (Satisfied = 91) Their families=140 (Satisfied = 57) DSS Mean=34.0, SD=6.62, Median=34.0 GHQ12 Mean=5.54, SD=4.08, Median=5.0 Hostile to MHS=223 subjects  Those who believe the psychiatrist over-prescribes medicine=208  Those who believes it is useless to receive MHS=83 Fig. 1 DDS; classification based on experiences of treatment at MHS Without treatment; N=213 Mean=32.5, SD=6.04, Median=33.0 With Treatment: N=196 Mean=35.6, SD=6.84, Median=36.0 Mann-Whitney U test U = 14834.5 p < 0.00001 ES = 0.25 Fig. 2 DDS of patients; classification based on satisfaction with treatment at MHS Dissatisfied N=105 Mean=37.1, SD=6.30, Median=37.0 Satisfied; N= 91 Mean=33.9, SD=7.06, Median=35.0 Mann-Whitney U test U = 3550.0 p = 0.002 ES = 0.23 Table 2. Predictors of DDS; Multiple Regression Analysis; N=409, R 2 =.10 Explanation Variablesβrp Working at MHS-0.83-0.089N.S. Experience of Treatment at MHS 1.460.22<0.0001 Hostility to MHS2.690.20<0.0001 Male-0.94-0.07N.S. Table 3. Predictors of Hostility to MHS of patients; Multiple Logistic Regression Analysis; N=196 Explanation VariablesβSEpOR95%Cl DSS0.0470.024N.S.1.051.00 – 1.10 Dissatisfaction with treatment at MHS 1.620.32<0.00015.072.69 – 9.56 Working at MHS0.420.26N.S.1.520.92 – 2.51 Table 4. Predictors of Hostility to MHS of not patients; Multiple Logistic Regression Analysis; N = 213 Explanation VariablesβSEpOR95%Cl DSS0.0720.024=0.0031.071.02 – 1.13 Dissatisfaction to their families` treatment at MHS 1.620.32=0.025.071.15 – 5.65 Table 5. Predictors of Hostility to MHS in those who did not receive treatment at MHS though their GHQ-12 score exceeded 2; Multiple Logistic Regression Analysis: N =150 Explanation VariablesβSEpOR95%Cl Working at MHS-0.3220.22N.S.0.720.47 – 1.12 DDS0.08620.029=0.0031.091.02 – 1.15 Many patients receiving MHS participated in our research. Self-experience of treatment at MHS raised interest in this theme. Many participants have hostility to MHS or dissatisfaction with their treatment. Many of them are not thought to have participated in any such survey in the past. Hostility can be expected to be a major cause of barriers to consultation. Many of those who are not treated at MHS in spite of having mental problems had hostility. Dissatisfaction with treatment was a major cause of stigma and hostility. Stigma and hostility exerted a major influence on each other. But because the effects of other factors were also found, it was not able to be said that stigma and hostility were the same things. Stigma and hostility in patients are greater than in non-patients. This may be a result of participation by many dissatisfied patients. But it must be noted how there were many dissatisfied patients who participated in this survey. Many patients may not be satisfied with treatment at MHS in Japan. These three elements: stigma, hostility and dissatisfaction with treatment, strongly influence each other. (Fig.3) To reduce stigma and hostility we must improve our skills in treating patients. StigmaHostility Dissatisfaction with Treatment Fig3 These three elements strongly influence each other. These three elements: stigma, hostility and dissatisfaction with treatment, strongly influence each other. Many patients may not be satisfied with treatment by MHS in Japan. To reduce stigma and hostility we must improve our skills in treating patients. Deflection was found in distribution. We were not able to adjust for this, although it was necessary, because of the small number of participants. It was not clear what kind of bias was at work. Note must be taken of bias when interpreting the results. DDS (Devaluation-Discrimination Scale ): Link BG, et al., Am Sociol Rev. 1987; 52,:96-112. DDS (Japanese version): Shimotsu, et al., Japanese Journal of Psychiatric Treatment, 2006; 21, 521-528 (Japanese article)