| Abstract|| |
Context: Attitude of fresh graduates toward psychiatric patients is important to bridge the treatment gap due to mental illness. Psychiatry as a subject has been neglected in the undergraduates of MBBS.
Aims: (1) To compare the attitude of medical students and interns in a medical college toward mental illness and psychiatry. (2) To assess the impact of psychiatric training on attitude toward the mentally ill person and mental illness.
Settings and Design: Cross-sectional, single assessment study conducted at a tertiary hospital.
Subjects and Methods: Participants consisted of medical students of 1 st and 2 nd year who didn't have any exposure to psychiatry and interns, who had completed their compulsory 2 week clinical posting in psychiatry. Participants were individually administered sociodemographic proforma, General Health Questionnaire-12 (GHQ-12), opinion about mental illness (OMI) scale, and attitude to psychiatry-29 (ATP-29) scale.
Statistical Analysis: Standard descriptive statistics (mean, percentage), Chi-square test.
Results: A total of 135 participants formed the study sample, with 48, 47, and 40 participants from 1 st year, 2 nd year and interns, respectively. Mean GHQ score was 14.03 for the entire sample. There was better outlook of interns toward psychiatry and patients with mental disorders in comparison to fresh graduate students in some areas. Overall, negative attitude toward mental illness and psychiatry was reflected.
Conclusions: Exposure to psychiatry as per the current curriculum seems to have a limited influence in bringing a positive change in OMI and psychiatry.
Keywords: Attitude, interns, mental illness, psychiatry, undergraduate students
|How to cite this article:|
Gulati P, Das S, Chavan B S. Impact of psychiatry training on attitude of medical students toward mental illness and psychiatry. Indian J Psychiatry 2014;56:271-7
| Introduction|| |
The World Health Organization reported in 2001 that about 450 million people worldwide suffer from some form of mental disorder or brain condition, and that one in four persons meet criteria for mental disorder at some point in their life.  Opinion about mental illness (OMI) plays a vital role in long-term care of patients with mental illness. Stigmatizing attitudes toward people with mental illness are widespread and people tend to react in a very discriminating way toward those with mental illness. ,,,,,
The treatment gap that exists in treating the persons with mental illness, due to an inadequate number of mental health professionals, especially psychiatrists, can be narrowed if the newly trained doctors have the acumen to spot those having a mental illness.  The knowledge and the attitude of the undergraduate medical students toward mental health and psychiatric disorders is of great importance as these individuals are going to be involved in the care of these patients either directly or indirectly during the course of their careers. Studies carried out to find out undergraduate medical students' OMI and their knowledge toward psychiatry have shown ignorance about scientific facts related to psychiatry, psychiatric patients, and treatment methods. , Medical graduates considered psychiatry to be imprecise, and unscientific and had unfavorable attitude toward considering psychiatry as a career option. 
However, providing clinical training in psychiatry during undergraduation seems to improve the attitude toward people with mental illness. ,,, However, psychiatry as a subject has not been given its due importance at the undergraduate level, which is reflected in the number of theory lectures and hours of psychiatry clinical posting.  Until recently, even during the internship posting, psychiatry used to be an optional subject as compared to compulsory posting in surgery, medicine, gynecology, among other branches.  Medical Council of India (MCI) had recently suggested to increase the number of hours for psychiatry into the curriculum of psychiatry for undergraduate MBBS course, but until date, only decision regarding internship has been implemented. 
There have been few studies in the past, all of which have assessed attitude of undergraduates toward mental illness/mentally ill or psychiatry separately, except one study from South India by Lingeswaran, which assessed both of these in a single study.  However, these studies have many limitations. First, these studies were carried out when psychiatry posting during internship was still optional, so the exposure to psychiatry could have been different amongst participants limiting their comparison. Second, presence of mental illness among the participants or their relatives was not ruled out, which would have an impact on their attitudes. Hence, the current study was planned to assess and compare the attitude of medical students and interns in a medical college toward mental illness and toward psychiatry. The author also attempted to assess the impact of psychiatric training on their attitude toward the mentally ill person and mental illness.
| Subjects and Methods|| |
This was a cross-sectional, single assessment study conducted at a tertiary hospital in North India. The participants consisted of medical students of 1 st and 2 nd year who didn't have any exposure to psychiatry as per MBBS curriculum, and interns, who had completed their compulsory 2 week clinical posting in psychiatry. Data were collected between June 2012 and November 2012. Students of 1 st and 2 nd year MBBS were approached as a group in their respective lecture theaters, whereas interns were approached individually on the last day of their psychiatry posting. After explaining them the aim of the study and obtaining their informed consent, participating students and interns were individually administered sociodemographic performa, General Health Questionnaire (GHQ-12),  OMI scale,  and attitude to psychiatry-29 (ATP-29) scale.  Names and roll numbers of the participants were omitted from the proforma to maintain the confidentiality.
- 1 st and 2 nd year students of MBBS course
- Interns who have completed their psychiatry posting as per curriculum.
- Students and interns having first or second degree relatives with current psychiatric disorder
- Students and intern undergoing treatment for mental health problems.
- Students and interns whose first or second degree relative were psychiatrist
- Students and interns who refused to participate.
- Demographic data was collected using a standard proforma being used routinely in the department and contained details such as age, gender, and socioeconomic status
- Each subject was administered the following scales.
- GHQ-12:  Score >15 was taken as an evidence of distress and score >20 suggested severe problems and psychological distress
- OMI scale:  The OMI scale investigates attitudes toward mental illness and consists of 51 items, in Likert format, with six alternative answers ranging from strongly agree to strongly disagree. Items define five factors, that is: Authoritarianism (A), benevolence (B), mental hygiene ideology (C), social restrictiveness (D), and interpersonal etiology (E)
- ATP-29 scale:  This scale measures attitudes using a four-point Likert type self-rated scale, with questions about attitude to psychiatric patients, illness and treatment, psychiatrists, psychiatric institutions, teaching, knowledge, and career choice.
Standard descriptive statistics (mean, percentage) were used to analyze the characteristics of participants. The differences between the students and interns were assessed using Chi-square test.
| Results|| |
In total, 135 participants formed the study sample, with 48, 47, and 40 participants from 1 st year, 2 nd year and interns, respectively. Of the 100 students in 1 st and 2 nd year, five students could not be approached due to their absence from classes on medical ground. All interns who had completed their psychiatry posting participated in the study. The percentage of male and female in each batch of students was: 1 st year (male 48%, female 52%); 2 nd year (male 28%, female 72%) and interns (male 52%, female 48%). The socioeconomic status was mostly upper middle class (102) and upper class (33) [Table 1].
The mean GHQ score was 14.03 for the entire sample. The group scores were as follows: 1 st year (11.7), 2 nd year (12.8), and interns (16.2). None of the participant had score >20, which ruled out any severe psychological problems in the study sample. 30 interns had a score of >15 when compared to 1 and 2 in 1 st and 2 nd year students, respectively.
Responses obtained on OMI scale were modified to agreed or disagreed to improve statistical significance to responses. No statistical differences were found between 1 st and 2 nd year students. Statistically significant differences between interns and other students were found on certain items [Table 2], [Table 3] and [Table 4].
|Table 2: Items reflecting positive attitude of both students and interns (OMI scale)|
Click here to view
|Table 3: Items reflecting negative attitude of both students and interns (OMI scale)|
Click here to view
|Table 4: Items reflecting difference in attitude between students and interns (OMI scale)|
Click here to view
Some of the items, pertaining to exposure to psychiatry during MBBS curriculum, were not applicable to 1 st and 2 nd year students and they were omitted from the analysis. No difference between 1 st and 2 nd year students was statistically significant. Statistically significant differences between interns and other students were observed for certain items [Table 5].
|Table 5: Items reflecting difference in attitude towards psychiatry (ATP - 29 scale)|
Click here to view
| Discussion|| |
The present study was carried out in a Medical College in North India to assess the impact of psychiatry training on attitude of medical students and interns toward mental illness and psychiatry. Physical and psychological well-being of the participants was also assessed using standardized questionnaires. Students of 1 st and 2 nd year, who didn't have any exposure to psychiatry as yet, and interns who had completed their psychiatry posting were included in the study. In addition to internship posting, interns were supposed to attend 20 theory lectures during their 6 th semester of MBBS as part of the curriculum. However, after checking the department attendance register, it was found that only 5% (2 out of 40) of the interns had attended 50% or more of theory lectures. The study highlights the fact that the majority of the students do not attend psychiatry theory lectures as the attendance in psychiatry classes is not mandatory and there is no separate examination in psychiatry. The findings support the long pending demand of making psychiatry an independent examination subject. Alternatively, if attendance in the subject of psychiatry is made compulsory like in other major subjects and more weightage is given to theory and practical examination in psychiatry as part of medicine examination, the students may be more attentive and have a better understanding of the subject.
The GHQ scores revealed better scores for 1 st and 2 nd year students than that of interns, indicating deterioration of psychological well-being with progression of MBBS course. None of the participant had score >20, which ruled out severe psychological and physical problems in the study sample. Of the 40 participating interns, 30 had GHQ score of >15, indicating significant distress among interns, which is an area of concern. Similar findings of increasing stress among interns was also reported in a recent study.  Reasons for increasing level of psychological distress among the interns could be diverse, including academic stress for preparing for entrance examinations for postgraduation, fatigue due to internship postings, issues pertaining to personal life, financial issues, etc.
Opinion about mental illness
It includes authoritarian submission and anti-intraception and reveals a view of people with mental illness as an inferior class requiring coercive handling and also indicates a belief that people with mental illness are inferior to normal individuals.  In our study, 1 st and 2 nd year students were found to have a negative view, when compared to interns on most of the questions. Approximately, 68% of the students felt that persons with mental illness should not be treated in the same hospital with people with physical illness and considered a mental illness as punishment for bad deeds, etc., Majority of the interns (70%) were against mental hospitals being surrounded by a high fence and guards, whereas students had mixed opinion. However, most of the students (65.3%) and interns (75%) were against keeping such patients behind locked doors. Both students (60%) and interns (72.5%) were also against punishing them in case they attacked someone in order to prevent future attacks. Most of the participants felt that people with mental illness were easy to recognize, and were different from patients suffering from other illness, e.g. a heart patient.
It reflects an orientation toward care in general.  Interns were of different, but favorable opinion toward people with mental illness than the students, as they considered that it was wrong to laugh over people with mental illness, and that more can be done for these patients except feeding them and keeping them comfortable (P < 0.05). Both students and interns favored supporting people with mental illness with money, who are unable to work and making patients comfortable in the mental hospital as if living in their homes.
Mental hygiene ideology
It reflects the positive orientation, which embodies the beliefs of the mental health worker and the tenets of the mental hygiene movement.  It's core concepts are summarized by the item "mental illness is an illness like any other." In the present study, interns considered mental illnesses to be like any other illness and did not consider people with mental illness to be dangerous. Interns did not consider that mental hospitals look like prisons and felt most people with mental illness are willing to work. However, both students and interns didn't consider them to be capable of skilled labor. Furthermore, 75% of interns opined that many of the patients would not remain in the hospital until they were well, if the doors were unlocked.
It explores the belief that people with mental illness constitute a threat to society, particularly to the family, and must therefore be restricted in their functioning during hospitalization and afterward.  In the current study, interns had a positive attitude toward some areas when compared to other students, e.g. allowing marriage of mentally ill patients and allowing small children of patients to visit them in mental hospitals. Both students and interns disagreed for disallowing mentally ill to vote and to prevent them from having children by a painless operation. However, they considered that people with mental illness don't care for their looks, and they will never be their old selves again. They did not consider that female patients can be trusted as baby sitters, and it would be dangerous to forget even momentarily that they are mentally ill. Students felt strongly against a woman marrying a man with a fully recovered severe mental illness, although interns gave mixed responses.
It is an area which reflects the belief that mental illness arises from interpersonal experience, especially deprivation of parental love during childhood.  Interns varied from students on the role of parenthood in mental illness as they did not consider that if children of normal people were raised by mentally ill, they would also become mentally ill. Both students and interns opined that if parents loved their children more, there would be less mental illness, and that separation or divorce of parents during childhood leads to more mental illness. Majority of interns, in contrast to students, did not consider that successful people would become mentally ill less often.
In a previous study from India using OMI scale, males and females from nonmedical background were compared. Negative attitude toward people with mental illness was reflected and no significant difference emerged between males and females with regard to mental illness.  In another study on medical students, using a different scale for assessing attitude toward mentally ill, overall negative outlook was reflected for psychiatry and patients with mental illness in spite of exposure to psychiatry during MBBS. 
Attitude to psychiatry
In the current study, attitude toward overall merit of psychiatry was evaluated. Results were found to be equivocal in all three groups when considering psychiatric research making good strides for care of major mental disorders. Psychiatry was not considered to be unscientific and imprecise by majority of both interns and students; however, only interns considered psychiatry to be an expanding frontier of medicine when compared with students (P < 0.05). In earlier studies, undergraduate students were found to believe psychiatry to be an imprecise, unscientific branch and did not believe it to be an expanding branch. ,
When considering psychiatric consultation and its usefulness to people who receive it, interns had a positive outlook, but it was not found to be statistically significant (P = 0.07) when compared with the rest of students. However, another study reported negative opinion about seeking psychiatric consultation.  Majority of the interns in the current study believed that psychiatric consultation was helpful for medical or surgical patients and that psychiatric treatment was useful to most patients who received it (P < 0.05).
To evaluate psychiatrist's role and functioning, participants were asked questions like "psychiatry is not a genuine and valid branch of medicine." Majority of the interns (75%) disagreed with the item and the difference in opinion was significant (P < 0.05) when compared with students. Although 77.5% of interns considered psychiatrists to be having the most authority and influence among mental health professionals, 40% of interns agreed with the item, "with few exceptions, clinical psychologists and social workers are just as qualified as psychiatrists to diagnose and treat emotionally disturbed persons."
The study also tried to examine the attitude of students and interns regarding prevalent view that "psychiatrists are abusing their powers for hospitalization of patients against their will." Majority of the interns as compared to the students (P < 0.05) did not agree with this view, similar to other studies. , While evaluating attitude of participants toward psychiatry as a career option and its personal rewards, it was found that psychiatry as a career option is being discouraged by the family members and fellow students and also, that status of psychiatry has been unfavorable among general public and other disciplines. Majority of the participants reported that in their opinion psychiatry residency is selected when other specialties are not obtained (73.68% of 1 st and 2 nd year students, 85% interns). Furthermore, majority of the participants reported that they felt uncomfortable with mentally ill patients. Unfavorable attitude toward psychiatry as a career was also reflected in another study. 
The study also tried to examine the participants' opinion on the attitude of hospital staff working in other departments. Approximately, 70% of interns and students in our study disagreed with the item "most nonpsychiatry and house staff at my medical school are respectful of psychiatry." The findings reflect disrespectful attitude of nonpsychiatry staff toward psychiatry. Approximately, 90% of interns felt that no effort was made to encourage them to become psychiatrists at their medical school, which reflects an alarming trend.
Although, in the current study, there is better outlook of interns toward psychiatry and patients with mental disorders when compared to fresh graduate students in some areas, their negative attitude cannot be ignored, e.g. considering mentally ill to be different from other patients, not considering them capable of skilled labor, not fit for sensitive jobs like babysitting, not being their usual self again etc., Similarly, negative attitude of medical students has been found in various other studies. ,, As reflected in the current study, exposure to psychiatry as per the current curriculum seems to have a limited influence in bringing a positive change in OMI and psychiatry and this finding was also observed in previous studies. ,,, As mentioned earlier, majority of the interns had not attended even 50% of their theory lectures, suggests that most of the observed change occurred during their internship only. Although, the current study did not evaluate the importance of duration of training, it seems to be an important aspect. In a study, it was found that a 4 week training posting in the specialty is required to significantly influence students' attitudes in a positive direction, as compared to 2 week posting.  Although, the current study did not evaluate the knowledge of psychiatry as a subject, but feedback of informal evaluation of interns by faculty at the time of signing their log books after completion of their psychiatry posting suggests that majority of them don't know the symptoms, diagnostic criteria and treatment of psychosis and depression, reflecting lack of basic knowledge about the subject.
With mental health disorders on the rise, negative attitude of health professionals for psychiatry, as a discipline, and lack of knowledge of mental disorders will only compound the problem of inability to provide psychiatry services in a country with poor patient-doctor ratio. Furthermore, findings of the current study emphasize the need of psychiatry as a separate subject. Although changes in psychiatry curriculum have been proposed, but they need to be implemented efficiently to bring any substantial change in attitude toward people with mental illness and develop a favorable opinion about psychiatry as a career option.
The sample size was small, as only 50 students are enrolled every year in MBBS course in the medical college. Furthermore, the current study was limited to one medical college setting, so generalization of results to other areas needs to be done with caution. Multi-centric studies are required to assess the impact of current curriculum of psychiatry across various colleges.
| Conclusion|| |
Majority of the students do not attend theory and practical classes in psychiatry during their undergraduate training as only 5% students attended more than half of the lectures. The recent proposal of MCI to increase number of hours of psychiatry training during undergraduate training will have limited impact on the psychiatry training. The interest and attendance in psychiatry can only be improved by making psychiatry an independent examination subject. Exposure to psychiatry as per the current curriculum seems to have a limited influence in bringing a positive change in OMI and psychiatry.
| References|| |
|1.||The World Health Report. Mental Health: New Understanding, New Hope. Geneva: World Health Organization; 2001. |
|2.||Thara R, Srinivasan TN. How stigmatising is schizophrenia in India? Int J Soc Psychiatry 2000;46:135-41. |
|3.||Loganathan S, Murthy SR. Experiences of stigma and discrimination endured by people suffering from schizophrenia. Indian J Psychiatry 2008;50:39-46. |
|4.||Byrne P. Psychiatric stigma: Past, passing and to come. J R Soc Med 1997;90:618-21. |
|5.||Link BG, Struening EL, Rahav M, Phelan JC, Nuttbrock L. On stigma and its consequences: Evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. J Health Soc Behav 1997;38:177-90. |
|6.||Porter R. Can the stigma of mental illness be changed? Lancet 1998;352:1049-50. |
|7.||Farina A. Stigma. In: Muesser KT, Tarrier N, editors. Handbook of Social Functioning in Schizophrenia. Needam Heights, MA: Allyn and Bacon; 1998. p. 247-79. |
|8.||Kallivayalil RA. The importance of psychiatry in undergraduate medical education in India. Indian J Psychiatry 2012;54:208-16. |
|9.||Mahto RK, Verma PK, Verma AN, Singh AR, Chaudhury S, Shantna K. Students' perception about mental illness. Ind Psychiatry J 2009;18:92-6. |
|10.||Chawla JM, Balhara YP, Sagar R, Shivaprakash. Undergraduate medical students' attitude toward psychiatry: A cross-sectional study. Indian J Psychiatry 2012;54:37-40. |
|11.||Lingeswaran A. Psychiatric curriculum and its impact on the attitude of Indian undergraduate medical students and interns. Indian J Psychol Med 2010;32:119-27. |
|12.||Tharyan P, John T, Tharyan A, Braganza D. Attitudes of 'tomorrow's doctors' towards psychiatry and mental illness. Natl Med J India 2001;14:355-9. |
|13.||Galka SW, Perkins DV, Butler N, Griffith DA, Schmetzer AD, Avirrappattu G, et al. Medical students' attitudes toward mental disorders before and after a psychiatric rotation. Acad Psychiatry 2005;29:357-61. |
|14.||Reddy JP, Tan SM, Azmi MT, Shaharom MH, Rosdinom R, Maniam T, et al. The effect of a clinical posting in psychiatry on the attitudes of medical students towards psychiatry and mental illness in a Malaysian medical school. Ann Acad Med Singapore 2005;34:505-10. |
|15.||Alexander PJ, Kumaraswamy N. Senior medical students' attitude towards psychiatry: Relationship with career interest. Indian J Psychiatry 1993;35:221-4. |
|16.||Goldberg DP, Williams P. A User's Guide to the General Health Questionnaire. Basingstoke: NFER-Nelson; 1988. |
|17.||Cohen J, Struening EL. Opinions about mental illness in the personnel of two large mental hospitals. J Abnorm Soc Psychol 1962;64:349-60. |
|18.||Balon R, Franchini GR, Freeman PS, Hassenfeld IN, Keshavan MS, Yoder E. Medical students attitudes and views of psychiatry: 15 years later. Acad Psychiatry 1999;23:30-6. |
|19.||Bulbena A, Pailhez G, Coll J, Balon R. Changes in the attitudes towards psychiatry among Spanish medical students during training in psychiatry. Eur J Psychiatry 2005;19:79-87. |
|20.||Rajagopalan M, Kuruvilla K. Medical students' attitudes towards psychiatry: Effect of a two week posting. Indian J Psychiatry 1994;36:177-82. |
Dr. B S Chavan
Head of Department, Department of Psychiatry, Government Medical College and Hospital, Sector 32, Chandigarh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]