Industrial Psychiatry Journal

ORIGINAL ARTICLE
Year
: 2012  |  Volume : 21  |  Issue : 1  |  Page : 22--31

Impact of psychiatric education and training on attitude of medical students towards mentally ill: A comparative analysis


Tarun Yadav1, Kishore Arya1, Dinesh Kataria1, Yatan Pal Singh Balhara2,  
1 Department of Psychiatry and De addiction, Lady Hardinge Medical College and Smt SK Hospital, New Delhi, India
2 National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences (AIIMS), New Delhi, India

Correspondence Address:
Yatan Pal Singh Balhara
Department of Psychiatry, National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences (AIIMS), New Delhi
India

Abstract

Background: A number of studies from the western world have explored the negative beliefs held by individuals towards people with mental illness. The knowledge of attitude and awareness of undergraduate medical students towards psychiatry, mental health and mental disorders is of utmost importance. Objective: The current study aims at assessment of attitudes of medical students towards mental illness and mentally ill. Materials and Methods: The study used a cross-sectional survey design. The instruments used included Beliefs toward Mental Illness (BMI) scale, Attitudes to Mental Illness Questionnaire (AMIQ). ANOVA was carried out to compare the in between group differences for the four study groups. Additionally Bonferroni correction was used to conduct the post hoc analysis. Results: The interns were significantly more likely to agree with the statement that the mental disorders are recurrent; less likely to be of thought that the behavior of people with mental disorders is unpredictable; more likely to disagree with the fact that diagnosis of depression as described in the case vignette was going to damage the career of the individual; more likely to agree with the option of inviting a depressed person to a party; more likely to believe in fact that mentally ill individuals are more likely to be criminals as compared to medical students in different professional years. Conclusions: Adequate modifications to existing medical curriculum would help improve attitude of medical students towards mentally ill.



How to cite this article:
Yadav T, Arya K, Kataria D, Balhara YS. Impact of psychiatric education and training on attitude of medical students towards mentally ill: A comparative analysis.Ind Psychiatry J 2012;21:22-31


How to cite this URL:
Yadav T, Arya K, Kataria D, Balhara YS. Impact of psychiatric education and training on attitude of medical students towards mentally ill: A comparative analysis. Ind Psychiatry J [serial online] 2012 [cited 2019 Jul 17 ];21:22-31
Available from: http://www.industrialpsychiatry.org/text.asp?2012/21/1/22/110944


Full Text

A number of studies from the western world have explored the negative beliefs held by individuals towards people with mental illness. [1],[2],[3] There is little work in non-western societies on psychiatric stigma. The need to study the issue assumes a greater significance in these societies as these have been dominated by non-western medical traditions. In most societies some supernatural, religious, moralistic, and magical approaches to illness and behavior exist. This can complicate the perception of mental disorders even further. Stigmatization of people with mental disorder not only affects the way people seek help individually. It also has enormous implications on the development of policy at a national level.

India, like most developing countries, has limited resources for health sector. The knowledge of the attitude and awareness of the undergraduate medical students towards psychiatry, mental health and mental disorders is of utmost importance. This is because these individuals are going to be involved in the care of the patients either directly or indirectly during the later years of their careers.

People tend to have strong beliefs about the mentally ill. Many of these concepts are based on prevailing local systems of belief. [4] These attitudes have important implications for planning of mental health policy and mental health program for the country. [5] Many people have prejudiced attitudes towards mentally ill individuals. Social stigma and negative attitudes can affect the quality of life for people with mental illness. There may be various reasons for this negative attitude. Lack of accurate information about mental illness, lack of contact with individuals with mental illness and lack of familiarity might be some of the most important reasons of these negative attitudes. [6] Such negative attitudes may be detrimental not only to the patient care but also to the society's attitude to mental disorders if they are present in the health professionals. Studies looking into the impact of education or information on attitudes of individuals towards mental illness and mentally ill have shown that education may have positive impact on the prejudice. [7]

Attitude of an individual determines orientation towards environment. Maximum part of attitude building towards different medical disciplines and the disorders takes place during the initial medical training. Therefore, attitude of medical students is of utmost importance. Most of the literature has shown negative attitude of the students towards psychiatry. [8] It has been seen that medical practitioners hold similar views about those with mental health problems as the population at large. Moreover these views were shown not always to be positive. The concept of iatrogenic stigma is used to describe the stigma caused or perpetuated by mental health professionals. [9] There is limited literature on the issue from India.

Role of education has been cited as integral to reduce stigma towards mentally ill. [10] Agencies concerning medical professional accreditation and training hold a key role in this regard. [11] Research has demonstrated the positive effects of completing undergraduate psychiatric training [12] and of specific education program [13] on attitudes of medical students. Use of experimental methods is recommended over the instructional methods for this purpose.

The present aimed at assessment of the impact of psychiatric education and training on attitude of medical students towards mentally ill and mental disorders. There is limited literature comparing medical students across different professional years on this issue. Studies either explore the attitudes towards mental illness or mentally ill. The present study aimed at assessment of both these aspects. A comparative study across successive training years would help understand the impact of undergraduate learning on attitude of medical students towards mentally ill and mental disorders. The findings would help understand the strengths and lacunae of the current undergraduate training in India.

 Materials and Methods



Participants

The study used a cross-sectional survey design. It was conducted among the medical students at a medical college in India. It included students from all three professional years and those doing their internship training. The study included a total of 452 completed responses from medical students and interns. It included 227 students from the first and second professional years, 92 from the third professional year part I, 57 from the third professional year part II and 76 interns. Almost all the participants were females (99%). This was so because the medical school enrolls only female students. It accepts male students only during internship. Majority of them were unmarried (98%).

Procedure

The students were approached in their lecture theaters and the clinical posting wards and were asked for their consent to participate in the survey. Those refusing to participate in the study were excluded.

Instruments

Semi structured proforma which included socio-demographic data (age, sex, semester, marital status, residence, religion, and socioeconomic status), family history and past historyBeliefs towards Mental Illness scale (BMI). The BMI is a 21-item self-report measure of negative stereotypical views of mental illness. There is a Total Score and three subscales based on factor analysis: dangerousness, poor social and interpersonal skills, and incurability. The poor social skills subscale also taps feelings of shame about mental illness and the perception that the mentally ill are untrustworthy. Items are rated on a six-point Likert scale ranging from 'completely disagree' (0) to 'completely agree' (5), with higher scores reflecting more negative beliefs. In the primary validity study, Cronbach's alpha was high among American (0.89) and Asian students (0.91). The measure holds promising evidence of validity [14] Attitudes to Mental Illness Questionnaire (AMIQ).

The 5-item AMIQ is a brief, self-completion questionnaire with good psychometric properties that can be used in most situations. Content validity and reliability is high, as indicated by Cronbach's alpha score, factor analysis and test-retest correlation coefficients. Vignettes describing highly stigmatized individuals (such as a convicted criminal) produce consistently negative scores and those describing non-stigmatized individuals produce positive scores. This indicates good face validity. [6]

The survey forms were distributed to 500 medical students and doctors. Those consenting to participate were recruited in the study. The response rate was high at 90%. The survey questionnaire was administered in an anonymous form and no identifiable information was collected from the participants. Conditions of anonymity and confidentiality were observed throughout the course of the study.

Statistical analysis

The data were analyzed using SPSS ver 17.0 ANOVA was carried out to compare the in between group differences for the four study groups. These groups included first/ second professional year students; third professional year part I students; third professional year part II students and interns. Additionally Bonferroni correction was used to conduct the post hoc analysis. Perason's correlation coefficient was used to calculate the correlation between different questionnaires and the level of training and education in terms of the professional years.

 Results



The study included a total of 452 completed responses from medical students and interns. It included 227 students from the first and second professional years, 92 from the third professional year part I, 57 from the third professional year part II and 76 interns. Almost all the participants were females (99%).

The mean scores (and standard deviation) of the four study groups on the Belief Towards Mental Illness (BMI) scale and Attitude to Mental Illness Questionnaire (AMIQ) have been presented in [Table 1] and [Table 2] respectively. In between group analysis for the different study groups using ANOVA with Post-hoc analysis for the Belief towards Mental Illness (BMI) scale and Attitude to Mental Illness Questionnaire (AMIQ) has been presented in [Table 3] and [Table 4], respectively.{Table 1}{Table 2}{Table 3}{Table 4}

Interns v/s first/second professional year students

Most significant differences were observed between the interns and the first/second professional year students. The interns were significantly more likely to agree with the statement that the mental disorders are recurrent (mean difference 1.02, SE±20, 95% CI 0.48-1.56; P<.05). There were significantly less likely to be of the thought that the behavior of people with mental disorders is unpredictable (mean difference .51, SE±.19, 95% CI -0.01-1.01; P<0.05). They were more likely to disagree with the fact that diagnosis of depression as described in the case vignette was going to damage the career of the individual (mean difference 0.60, SE±0.16, 95% CI -0.16-1.03; P<0.05) and they were more likely to agree with the option of inviting a depressed person to a party (mean difference 0.52, SE±0.13, 95% CI -0.17-0.88; P<0.05). They were also comparatively less likely to believe that the wife of a person with OCD is going to leave him because of his mental condition (mean difference 0.38, SE±0.13, 95% CI -0.02-0.74; P<0.05). The interns were more likely to believe in the fact that the mentally ill persons are more likely to be criminals (mean difference 0.21, SE±0.07, 95% CI -0.04-0.39; P<0.05). They also found media reports to be more favorable with regards to 'projecting negative image of those with depression and psychosis' (mean difference 0.19, SE±0.06, 95% CI -0.02-0.36; P<0.05).

Interns v/s third professional year part I students

Interns were more likely to disagree with the fact that diagnosis of depression as described in the case vignette was going to damage the career of the individual (mean difference 1.021, SE:±0.24, 95% CI -0.39-1.65; P<0.05) and they were more likely to agree with the option of inviting a depressed person to a party as compared to the third professional year part I students (mean difference 0.81, SE±0.19, 95% CI -0.30-1.32; P<0.05).The interns were more likely to believe in the fact that the mentally ill persons are more likely to be criminals (mean difference 0.53, SE±0.16, 95% CI -0.11-.94; P<0.05).

Interns v/s third professional year part II students

The interns were more likely to believe in the fact that the mentally ill persons are more likely to be criminals as compared to the third professional year part II students (mean difference 0.91, SE±0.27, 95% CI-20-1.62; P<0.05).

Pearson's coefficient of correlation was calculated to find out degree of correlation between the level of medical education and different questions of the two scales used in the study. Significant correlations were observed between level of medical education and items 'Likelihood of wife of heroin user to leave him' (r=-0.116, P=0.02); 'Likelihood of depression damaging ones career' (r=-0.127, P<0.05); 'Level of comfort having someone with depression as colleague at work' (r=0.097, P=0.04); 'Likelihood of schizophrenia damaging ones career' (r=-0.113, P=0.018); ' Likelihood of wife of patient with schizophrenia to leave him' (r=-0.160, P=0.00); and 'Likelihood of mentally ill to be criminals' (r=-119, P=0.01) [Table 5].{Table 5}

 Discussion



The current study made use of a survey based methodology to study the attitude of medical students towards mental illness and mentally ill. Additionally, a comparative analysis was carried out between the students from different professional years in order to assess the impact of the medical education and training on these aspects.

There is limited information on the impact of the medical education and training on the attitude towards mentally ill among Indian students. [15] The assessment was done among a total of 452 medical students.

There were significant differences between the interns and the students from different professional years. Overall interns were found to have more favorable attitudes towards mentally ill as compared to the medical students from different professional years as assessed by BMI scale and AMIQ. They were more firm believer in the fact that mentally ill is likely to find support from the spouse. They were more comfortable in having interaction with mentally ill in social and professional settings. Similarly a negative correlation was observed between the stigmatizing attitude and level of medical education and training with a progressive increase in favorable attitudes along increasing years of medical education.

Patients suffering from schizophrenia, alcohol and drug problems were reported as dangerous, unpredictable and different looking in another study. [8] Negative attitude were also observed for those with depression, regarding predictability, ability to talk to, and their ability to pull themselves together and focus of blame in this study. Negative attitudes towards blame and ability to pull oneself together were also noticed for those with alcohol and drug problems.

In a previous study from India, undergraduate medical students were found to have multiple lacunae in their knowledge toward psychiatry, psychiatric disorders, psychiatric patients and psychiatric treatment. [16] The interns are likely to have the maximum exposure to psychiatric patients and mental disorders. Maximum differences were observed between the interns and the first/second professional year students- a finding reflective of the fact that exposure to psychiatry teaching and training can module the negative attitude towards the mentally ill people. Since the first/second year students are not exposed to any psychiatry lectures or ward postings their understanding in to these conditions is expected to be minimal. With gradual exposure to lectures (from third professional year I onwards) and ward postings (from third professional year part II onwards) there is a progressive increase in the understanding and awareness of the psychiatric conditions. This could be the detrimental factor for reduction in negative attitude and biases of the medical students. The findings of correlation between the level of psychiatry education/training and different parameters assessed also corroborate this explanation. The favorable impact of psychiatry posting on the attitude of medical students towards mentally ill has been found in previous studies from western countries. [17] Work by Mas and Hatim (2002) from Malaysia found that final year MBBS students had more favorable attitude towards mentally ill as compared to the first year students. [18]

High levels of ignorance, prejudice and discrimination towards mentally ill has been confirmed by studies among health professionals in Australia, Brazil, Canada, Croatia, England, Malaysia, Spain and Turkey. [17],[18],[19] Studies among medical students have also reported unfavorable attitudes towards mentally ill. [20],[21],[22],[23]

Role of medical education in addressing stigma towards mentally ill has been debated by certain authors. [24] A study by Ay et al. (2006) failed to find a favorable impact of medical education on stigmatizing attitudes of medical students towards mental illness. [25]

Role of education has been cited as integral to reduce stigma towards mentally ill. [11] Agencies concerning medical professional accreditation and training hold a key role in this regard. [11] Research has demonstrated the positive effects of completing undergraduate psychiatric training [12] and of specific education program [13] on attitudes of medical students. Use of experimental methods is recommended over the instructional methods for this purpose.

It has been recommended to design program for medical students based on policy of 'catch them young'. [26] The clinical rotation in psychiatry has been found to be an important factor influencing medical student attitudes towards psychiatry. [27],[28] A one hour supplementary education program in addition to the traditional medical curriculum led to significant improvement in attitude of medical students towards mentally ill in Japan. [29],[30]

The knowledge of the attitude and awareness of the undergraduate medical students towards psychiatry, mental health and mental disorders is of utmost importance as these individuals are going to be involved in the care of these patients either directly or indirectly during the later years of their careers. An overwhelming majority of patients with neurosis, depression, alcohol-related problems, sexual problems and psychosomatic disorders have been found to seek treatment from general physicians in India. [31] The need to impart adequate psychiatry training to even those medicals students who might specialize in other specialties later on has been expressed. [32]

Concerns have been expressed over the reduction in funding for medical student education-related roles and positions within departments of psychiatry. [33] Psychiatry as a discipline is felt to be given a step motherly treatment at the undergraduate level which is reflected in the number of lectures in psychiatry and number of hours of psychiatry clinical posting. Very recently psychiatry rotation has been made compulsory during the internship in India. This is a welcome move. However, much more needs to be done in this direction. Even a brief one hour orientation session of the first year medical students helped improve their attitude towards mental illness. [5]

Limited number of psychiatry trainees in the country make the issue even more relevant. There are just 0.4 psychiatrists and 0.02 psychologists per 100,000 people. The recent publication by WHO and WPA title 'Atlas: Psychiatric Education and Training Across the World 2005' has highlighted the limited mental health professionals in the country. [34]

The current has certain strengths. We made use of a survey based methodology. The survey had a high response rate. Additionally we assessed students across different professional years during the medical school. The assessments were made using standardized instruments and hence the findings are comparable with those of the other studies. The reasons for studying psychiatric stigma specifically among medical students were twofold: (a) doctors can play an important role in reduction of stigma; (b) the findings will help to focus education and other strategies to change attitudes in this group.

However, we made a cross sectional evaluation. It would be interesting to follow up the cohort prospectively and assess the change over time. Also impact of these attitudes on behavior of these students can also be assessed when they start their own clinical practice. Also we have assessed only female students due to logistic reasons. Future studies should include male students as well. It would be interesting to compare the findings from other medical schools across different regions and cultures. This would be important before the findings could be generalized to other parts of the country.

 Conclusions



Attitude of medical students is detrimental to the care of the mentally ill persons. The negative attitude of the medical students is amenable to psychiatric education and training. Hence, adequate modifications to the existing medical curriculum would help improve the attitude of medical students towards mentally ill.

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