Attitude towards psychiatry and mental illness among medical students: A cohort study

Study design and setting

This was an observational study on a cohort of medical undergraduates. Participants recruited for this study were second clinical year medical students who were posted in the Department of Psychiatry for their psychiatry rotation. A 122-bed hospital attached to the department provides short-term care for patients from the local area and also functions as a tertiary referral centre for patients with mental illness from different parts of India and neighbouring countries. The approach is multidisciplinary, using a range of pharmacological and psychological therapies.

Curriculum and setting of psychiatric education

The psychiatry curriculum in this institution had been modified a few years before this study, with the aim of equipping students with the knowledge and skill required to identify and manage common psychiatric presentations that they would encounter in general practice.¹¹ During the psychiatry posting, lectures and clinics of the first half of the day were conducted in the outpatient clinics of the Community Health and Family Medicine departments with a focus on familiarising the students with the psychosocial context of patients’ medical problems and the recognition and management of common mental disorders. The afternoon sessions were held at the Department of Psychiatry, where other psychiatric presentations were taught. The students were familiarized with history-taking, physical examination and basic laboratory investigations to identify or exclude medical causes of the psychiatric presentation. They were taught the fundamentals of the mental state examination to evaluate cognitive abilities, mood and psychotic symptoms and were also taught communication and basic counselling skills. The total duration of the rotation was 3 weeks.

Subjects

All medical students who were posted in the department of psychiatry for their clinical rotation in 2019 and 2020 were eligible to participate in the survey.

Procedure

Students were invited to participate in the study on the 1st day of the psychiatry rotation before the first teaching session. Written informed consent was obtained after which the study questionnaires were administered. On the last day of the rotation, they were asked to complete the same questionnaires. The students were contacted 1 year after the rotation and again asked to complete the same questionnaires. Students entered their roll number on the questionnaires to enable linking of assessments.

Instruments used

1. The AMI scale has 20 items that examine attitudes towards the causes, treatment and consequences of mental illness and its impact on individuals and society. Item responses are rated on a 5-point Likert scale with a score of 3 on an item suggesting neutral attitude.

2. The ATP-30 scale is a 30-item, Likert-type scale that examines attitudes to psychiatric patients, psychiatric illness, psychiatrists, psychiatric career choice, psychiatric drugs, psychiatric treatment, psychiatric institutions and psychiatric teaching. For both scales, the total is calculated by adding individual item scores, higher scores indicating positive attitudes. These questionnaires have been widely used in attitudinal studies on medical students and have been shown to have adequate face and construct validity.^12–14

3. Socio-demographic and clinical variables were collected using a specially designed proforma.

Ethical considerations

The study was approved by the Institutional Ethics Committee (IRB Min No. 11910 dated March 06, 2019 and IRB Min. No. 12966 dated May 24, 2020). The survey was conducted in the classroom ensuring privacy. The principal investigator and another psychiatrist were available during the data collection to clarify participant’s doubts.

Statistical methods

Mean and standard deviation (SD) was calculated for continuous variables and frequency distributions for categorical data. T-test and Chi-square test were used to test associations for continuous and categorical variables and ATP and mental illness at 1 year. Total scores in ATP-30 and AMI at the three points of assessment were compared by Repeated Measures of Analysis of Variance (RMANOVA). The categorized ordinal scores of ATP and AMI among the 3-time points were compared using a population- averaged ordered logistic regression model. The interactions were tested for gender in the corresponding models. Negative attitudes in individual items on the ATP-30 and AMI at the three points of assessment were compared using Cochran’s Q test. The data were analysed using SPSS for Windows (version 16.0.1) and STATA IC/16.0.

Socio-demographic variables

The socio-demographic details of the sample are summarized in Table I. Nine students had studied psychology before joining medical school. Fourteen students (13.6%) reported a family history of psychiatric illness, while 4 (3.9%) reported a personal history of mental health problems before the rotation. Eight students (7.8%) reported that someone in their immediate family was diagnosed to have a mental illness and 4 (3.9%) stated that they developed mental health issues in the year after the rotation.

Psychiatry as a future specialty

Twenty-two (21.4%) students stated that they had thought of psychiatry as a future specialization before joining medical school. More men (27.9%) than women (16.95%) reported an interest to specialize in psychiatry; however, this difference was not statistically significant (p=0.18). Students who had studied psychology before joining medical school (p=0.02) and those with a family history of mental illness (p=0.04) were more likely to opt for psychiatry as a future career speciality. However, at the 1-year follow-up, only 19 (18.4%) students stated that they were considering psychiatry for specialization after completing their course. Students with family history of mental illness before the rotation (p=0.01), having studied psychology (p=0.01) or political science (p=0.04) before medical school and new-onset mental health issues in self (p=0.02) were more likely to consider psychiatry for specialization at the 1-year follow-up assessment.

ATP

The mean (SD) ATP-30 score of the group before the rotation was 102.19 (11.35) suggesting an overall positive ATP. The scores were higher among women (103.8 [10.29]) than men (100.05 [12.43]); however, this was not statistically significant. The mean ATP-30 score after the rotation increased to 106 (14.62) and remained higher among women 106.78 (12.14) than men 104.95 (17.51). The mean ATP-30 scores at 1 year were 105.65 (13.16) and the mean scores were higher among women 106.71 (13.34) than men 104.19 (12.93), though this was not statistically significant. RMANOVA revealed that time was the only factor that influenced the ATP-30 scores (p=0.003). Gender and time*gender interactions did not influence the scores (Table II).

Positive ATP (ATP-30 ≥91) at 1 year follow-up was associated with positive attitude before the rotation (p<0.001) and positive attitude after the rotation (p<0.001). Gender, family history of mental illness, past history of mental illness and studying psychology, economics or sociology before medical school were not associated with positive or negative ATP (Table III).

There was a reduction in the number of students with negative ATP (pre-rotation 12, post-rotation 11, 1-year follow-up 8). A similar change was evident in students with positive attitudes and a consequent increase in students with neutral attitudes. Population averaged random effects model ordinal logistic regression used to test the effects of time, gender and time*gender interaction on ATP did not show any statistically significant interactions (Table IV).

AMI

The mean (SD) AMI scores before the rotation were 65.32 (5.92; range 52–80) suggesting an overall positive attitude and were higher among women 65.75 (5.9) than men 64.75 (5.95). The mean AMI score after the rotation slightly increased to 66.04 (7.13; range 46–85) and was also higher among women 66.63 (6.44) than men 65.25 (7.98). The mean AMI score at 1 year follow-up was 66.51 (8.23) and this also was higher among women 67.94 (6.97) than men 65.23 (9.65). RMANOVA revealed that time, gender and time*gender interaction did not influence the AMI scores (Table II).

Positive AMI (AMI ≥61) at 1-year follow-up was associated with positive ATP before the rotation (p=0.02), after the rotation (p=0.03) and positive AMI after rotation (p=0.001). Age, gender, family history of mental illness, past history of mental illness and having studied psychology, economics or sociology before medical school were not associated with positive or negative AMI at 1-year follow-up (Table III).

There was a reduction in the number of students with negative AMI (pre-rotation 16, post-rotation 14, 1-year follow-up 12).

A similar change was evident in students with positive attitudes and a consequent increase in students with neutral attitudes. Population averaged random effects model ordinal logistic regression used to test the effects of time, gender and time*gender interaction on attitudes did not show any statistically significant interactions (Table IV).

Negative attitudes about psychiatry and mental illness

There was a reduction in number of participants with negative attitudes on individual items of the ATP-30 except for questions related to respect for psychiatry as a subject and perceived satisfaction levels of a career in psychiatry as compared to other specialties. However, at 1-year follow-up, more than a quarter of the participants had negative attitudes towards statements like ‘the majority of students report that their psychiatric undergraduate training has been valuable’, ‘psychiatric treatment causes patients to worry too much about their symptoms’, ‘if I were asked what I considered to be the three most exciting medical specialties, psychiatry would be excluded’ and ‘these days psychiatry is the most important part of the curriculum in medical schools’ (Table V).

Similarly, there was a reduction in number of respondents with negative attitudes on individual items on AMI except for questions related to giving a person with mental illness a job with responsibility, liver transplantation for people who sustain liver damage due to attempted suicide and compassionate care of people after a deliberate self-harm and genetic origins of mental illness. At 1-year of follow-up, more than 25% of respondents had negative attitudes to statements like ‘violence mostly results from mental illness’, ‘psychiatric drugs are mostly used to control disruptive behaviour’, ‘it is preferable that the mentally ill live independently rather than in hospital’, ‘alcohol abusers have no self-control’, ‘mental illnesses are genetic in origin’, ‘people who had good parenting as children rarely suffer from mental illness’ and ‘patients with chronic schizophrenia are incapable of looking after themselves’ (Table V).

ATP

The study participants as a whole had a positive ATP at all three assessment points, similar to previous study findings.¹⁶ While this study was similar to another from Ethiopia which reported more women to have a positive ATP, it differed in that personal and family history of mental illness were not found to be associated with a more positive attitude.⁵

A statistically significant improvement in ATP scores was found immediately after the rotation and at 1-year of follow-up as compared to baseline, though the scores did not differ significantly between these two assessments. Previous reports have variably reported the rotation to have a positive influence, or no measurable change.^12,16 Contrary to previous reports of male students having greater improvement in positive attitudes, gender did not seem to influence change in ATP among participants of our study.¹⁷ The first exposure to psychiatry in medical school may contribute to a relatively enduring set of attitudes toward the subject.^18,19 Direct involvement of the student in the care of patients, watching patients responding favourably to the treatment and having a satisfactory interaction with staff and patients at a psychiatric centre have been found to create a positive impact. While no specific component of the rotation was found to be associated with improved attitudes, as in previous research,²⁰ it is possible that the setting and content of the psychiatry teaching used in our study helped to create better awareness among students that emotional and psychological problems are widely prevalent, even among patients attending general medical clinics, and not just among those seeking specific psychiatric help. This improved understanding may have played a role in the persistence of favourable attitudes 1 year after the rotation.

Factors such as encouragement by colleagues, enrichment activities such as clerkships and psychiatrists as role models have been shown to positively influence medical students’ choice of psychiatry as a future career. On the other hand, barriers include the poor public image of psychiatry, a perceived lack of respect towards psychiatry by other specialists, low morale among psychiatrists and the physical risks associated with the specialty; efforts should be made to address these aspects during psychiatry rotation.^15,21

AMI

People with mental illnesses can be perceived by medical students as dangerous, unpredictable and untreatable, resulting in an unwillingness to engage with such persons.²¹ This unfavourable attitude spills over to psychiatry as a career choice. However, medical students are also considered to be ideal for anti-stigma interventions as their attitudes are easier to modify.^22,23

Our study participants as a whole had positive AMI before their exposure to psychiatry, after the clinical rotation and at 1-year follow-up, in contrast to reports from Pakistan and South Africa.^24,25 More women than men reported a positive AMI before the rotation, as described earlier.^25,26 Unlike previous reports from Australia, North America and Europe, the increase in AMI scores after the rotation in our study were not statistically significant which may be attributed to the short duration of the rotation.^14,27–29 Previous literature has suggested that psychiatric training undertaken in a general hospital setting improves ATP more than a specialty hospital, while AMI is better when the training is set in a specialty hospital.²³ The students who participated in this survey had psychiatric training in both a general hospital and specialty hospital setting; however, a statistically significant change was found only in ATP. In contrast to other reports from India, Malaysia and Nigeria, there was no greater improvement of AMI among female medical students after the rotation in this study.^12,30,31 Change in AMI is considered to be due to a complex interaction between acquisition of knowledge, awareness of the therapeutic potential of psychiatric interventions and direct patient contact. It is suggested that change is most likely to happen if the pre-rotation responses are neutral, since least rigid and stereotypic attitudes show most change.^12,14

While attitudes may be more difficult to change if much value is placed on rewards such as money and prestige from a career in psychiatry, negative opinions about psychiatry and mental illness that stem from erroneous or insufficient knowledge can be corrected through medical education.³² Several measures have been suggested to improve attitudes among medical students towards mental illness and psychiatry. These include introducing psychology or behavioural science modules in the pre-clinical years, increasing the duration of psychiatry rotation to 6–8 weeks and increasing clinical contact during this period, integrating psychiatric teaching with medical and surgical teaching, teaching basic counselling skills and assessing knowledge and competence of psychiatry in university examinations.^12,21

Strengths and limitations

Our study included a follow-up assessment 1 year after the rotation, in addition to immediately after rotation. The population studied was heterogeneous consisting of students from diverse socio- economic and cultural backgrounds. There was no selection bias as all students in the rotation were included. The questionnaires used for the survey have good psychometric properties and have been used extensively in the region. The limitations include the lack of a control group which eliminated the opportunity to account for the effects of maturation on attitudes; attitudes are context dependent and some of the group’s responses should be seen in this light. A structured training and assessment method would have made the study methodologically stronger. As the data were obtained from only one medical school, the results cannot be generalized.

Conclusion

Overall, medical students have positive ATP and mental illness even before exposure to psychiatric training. Clinical rotation in psychiatry improved on these attitudes further and this effect persisted even after 1 year. Despite this, recruitment rates to psychiatry training programmes remain low, leading to workforce shortages and inadequacy of mental health services in the community. Future research should focus on the benefits of modifying the curriculum to incorporate activities such as psychiatry electives and altering medical school admissions criteria to include more students from humanities and non- science backgrounds.