Attitude of interns towards mental illness and psychiatry: A study from two medical colleges in South India

Accepted Manuscript Title: Attitude of Interns towards Mental illness and Psychiatry: A study from two medical colleges in South India Author: Krishna Kodakandla Minhajzafar Nasirabadi Mohammed Shahid Pasha PII: DOI: Reference:

S1876-2018(16)30078-8 http://dx.doi.org/doi:10.1016/j.ajp.2016.06.008 AJP 892

To appear in: Received date: Revised date: Accepted date:

24-2-2016 20-5-2016 19-6-2016

Please cite this article as: Kodakandla, Krishna, Nasirabadi, Minhajzafar, Pasha, Mohammed Shahid, Attitude of Interns towards Mental illness and Psychiatry: A study from two medical colleges in South India.Asian Journal of Psychiatry http://dx.doi.org/10.1016/j.ajp.2016.06.008 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

1. Type of manuscript: Original Article 2: Title: Attitude of Interns towards Mental illness and Psychiatry: A study from two medical colleges in South India 3. Authors Names: First Author: [Given Name] Krishna [Family Name] Kodakandlaa Co-Author 1: [Given Name] Minhajzafar [Family Name] Nasirabadib Co-Author 2: [Given Name] Mohammed Shahid [Family Name] Pashac

4. Authors affiliation & address: a. Assistant Professor, Dept of Psychiatry, Shadan Institute of Medical Sciences. Address: Dept of Psychiatry, Shadan Institute of Medical Sciences, Peeramcheru, Near Kalimandir, Chevella Road, Hyderabad, Telangana, India 500 086 Email: [email protected] b. Professor, Dept of Psychiatry, Dr V.R.K Women’s Medical College. Address: Dept of Psychiatry, Dr V.R.K Women’s Medical College, Aziznagar, Ranga Reddy District, Hyderabad, Telangana, India 500 075. c. Intern, Shadan Institute of Medical Sciences Address: Dept of Psychiatry, Shadan Institute of Medical Sciences, Peeramcheru, Near Kalimandir, Chevella Road, Hyderabad, Telangana, India 500 086 5. Corresponding Author Details: Dr Krishna Kodakandla, M.D, Assistant Professor, Dept of Psychiatry Shadan Institute of Medical Sciences, Peeramcheru, Near Kalimandir, Chevella Road, Hyderabad, Telangana State, India. 500 086. Email: [email protected]

Highlights The opinion about mental illness among medical interns continues to remain negative The attitude towards psychiatry, psychiatrist and treatment efficacy is positive Social and reward aspects of Psychiatry are considered to be low Few students consider psychiatry as their career choice

Introduction: With change in the life style, social and family dynamics worldwide, psychiatric illnesses are on the rise over the past few years. The World Health Organization (WHO) reported in 2001 that about 450 million people worldwide suffer from some form of mental disorder or brain condition. Four of the ten leading causes of disability worldwide are neuropsychiatric disorders, accounting for 30.8% of total disability and 12.3% of the total burden of disease. This latter figure is expected to rise to 15% by the year 2020. The WHO 2001 Report predicted that by the year 2020, depression will have jumped to second place. A secondary analysis of the data of

National Sample Survey

Organization report (2002) by Lakhan and Ekundayo in 2015 found that the cumulative prevalence rate of mental illness in rural India was 17.10/1000, in urban India it was 12.7/1000 and in combined population of the nation it was 14.90 persons per 1000. An epidemiological review of prevalence studies of psychiatric disorders from 1960 to 2009 (Math and Srinivasaraju, 2010) found that the prevalence of mental illness falls in the range of 9.5-370 persons per 1000. Future demands of psychological health care providers: In United States, the demand for general psychiatry services is predicted to increase by 19% from 1995 and 2020 (2012 Review of Physician Recruiting Incentives Survey). In India, according to the Union ministry of health and family welfare there are 3500 psychiatrists against the required 11,500 (“Shortage of psychiatrists hits treatment Times of India,” n.d.) Another study (Thirunavukarasu and Thirunavaukarau, 2010) found the average national deficit of psychiatrists in India to be 77%. However medical graduates across the world seem reluctant in choosing psychiatry as their career. One reason could be due to misconceptions and stigma about the specialty. Secondly, psychiatry is given little emphasis during the teaching of undergraduate medical students. World’s perspective on undergraduate psychiatry: The shortage of psychiatrists is globally prevalent depending upon the emphasis given for psychiatry education at the undergraduate level. In most of the countries, the status of psychiatry at the undergraduate level is at the developing phase. In Denmark where psychiatry is a full fledged subject, with approximately 240 hrs of teaching, it is the third major clinical subject of choice (Gupta and Khurana, 2015). In USA, there is 60 hrs of teaching during

the first two years, 30 hrs of practical teaching n the third year and 8 weeks of clinical postings in the final year. In Sri Lanka and Nepal, passing in psychiatry examination is mandatory to be qualified for a medical degree (Kallivayalil, 2012). In India, the duration of psychiatry lectures and clinical postings is much less compared to the National needs (Chawla et al., 2012) and the time allotted is just 1.4 % of the total time (Thirunavukarasu and Thirunavaukarau, 2010). With this background we have conducted a study to assess the opinion and attitude of Interns towards mental Illness, psychiatry, and psychiatry as a career choice.

Material and Methods: This is a cross-sectional study conducted at two private medical colleges, [Shadan Institute of Medical Sciences (SIMS) and Dr. Vizarath Rasool Khan Institute of Medical Sciences (VRK)] located in the suburb of Hyderabad, a metro city in South India. While SIMS* is a medical college with predominantly female students, VRK† is an exclusively women’s medical college. Both of them have a General Hospital Psychiatry set up. The teaching program in both the medical colleges consisted of 20hrs of psychiatry lectures in final year and 2 weeks of clinical postings in 5th semester. The departments run both the outpatient as well as inpatient services. Inpatient services include 15 beds in SIMS and 10 beds in VRK with one unit in both the colleges. Students are predominantly exposed to outpatient settings. There are no subspecialty clinics and no post graduate training program in either of them. Psychiatry is a part of medicine and there is no separate examination for the subject. Interns have 2 weeks of psychiatry rotation as a part of medicine rotation. The set up and teaching program is in accordance with the norms of Medical Council of India (MCI). The study was approved by the Institutional Ethics Committee. The participants were Interns, who completed their psychiatry rotation. Data was collected from April 2015 to December 2015. After obtaining their informed consent, Interns were individually administered a proforma designed for the present study, Beliefs towards Mental Illness scale and Attitude to Psychiatry-29scale. Identity of the participants was kept confidential.

Tools o

A proforma that contained details such as sociodemographic details, exposure to psychiatry via academic or non academic means – attendance in lectures/postings/reading psychiatry, doctors/psychiatrist/psychologists in the family and history of mental illness in the family/close friends and question pertaining to interest in psychiatry as a career.

o

Beliefs towards Mental Illness scale (Hirai and Clum, 2000) (BMI). The BMI is a 21-item selfreport 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. Items are rated on a six-point Likert scale ranging from ‘completely disagree’ (0) to

*

Shadan Institute of Medical Sciences

†

Dr Vizarath Rasool Khan Institute of Medical Sciences

‘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 o

Attitude to Psychiatry (ATP)-29 scale (Balon, et al., 1999): 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.

Statistical analysis: Data was analyzed using SPSS version 20. Descriptive analysis was carried out using mean and Standard Deviation (SD) with range for continuous variables and in terms of frequency and percentages for categorical variables. Results: Mean age of the sample was 23.2 years (SD, 1.06). Of the 176 Interns who participated in the study, 111 were from SIMS and 65 were from VRK. Of the 111 participants from SIMS, 78 were females and 33 were males. All the 65 participants from VRK were females, it being a women’s medical college. Majority of them belonged to Islam community (94%) and from urban schooling background. Non academic exposure: Profile of the Intern’s parents showed that 90% of them were from non medical background and around 10% doctors. Only 7 (4%) of them had a psychiatrist/psychologist in the family. History of family member or close friends visiting a psychiatrist was found in 13% and 16.5% respectively. Academic exposure: As shown in Table 1, Less than 20% of the students had 75% attendance in lectures. Only 30% of them had 75% attendance in clinical postings. Only one fourth (26%) have read most of the topics in psychiatry. Tables 2, 3 and 4 show the scores on the dangerousness subscale, the interpersonal and social skill subscale and the incurability sub scale of BMI scale respectively. Dangerousness: Majority (76%) of the Interns believed that mentally ill person is more likely to harm others and that mental illness require a much longer time to be cured than other general diseases. However majority of them (71%) were not afraid of mentally ill patients and did not consider mentally ill patients to be criminals (71%). Interpersonal and social skill: Around two third of them (62%) believed that it may be difficult for mentally ill patients to follow social rules and that they are less likely to function well as parents (63%). More than three fourth (82%) believe that mentally ill patients should have a job with minor responsibilities. Responses on the other items of the subscale were equivocal. Incurability: Majority of them (76%) believed that psychological disorder is recurrent and that the behavior of patients with psychological disorder is unpredictable (79%). Two third of them (68%) were of the opinion that people who have once received psychological treatment are likely to need further treatment in the future. One third (31%) believed that psychological illness is unlikely to be cured regardless of the treatment. Responses on rest of the items of the subscale were equivocal. Tables 5 and 6 show the scores on ATP scale.

Overall merits of psychiatry: Most of them (93%) agreed that psychiatric research has made good progress in advancing care of major mental disorders and that it is a rapidly expanding field of medicine (86%). One third (31%) found psychiatry as unscientific/ imprecise. Efficacy: Most of them (90%) consider psychiatric treatment to be helpful to the most who received it. Role definition and functioning of the psychiatrist: A good majority of the Interns considered psychiatry as a valid branch of medicine (91%) and psychiatrist as clear logical thinkers (82%). Psychiatrists were considered to be having the most authority among mental health professionals (73%). However about half of them (45%) were of the opinion that clinical psychologist and social workers are equally qualified to diagnose and treat emotionally disturbed patients. Career and personal reward: Almost half of them (48%) opined that psychiatry has low prestige among general public. Around 42% of the Interns were uncomfortable with mentally ill patients. About 40% of the Interns were of the opinion that most people who could not get a residency position in other specialty enter psychiatry and over one third (36% ) were discouraged by family members from entering psychiatry. Medical school factors: More than three fourth (78%) found psychiatry teaching as interesting and of good quality, psychiatrist as good role models (77%) found non psychiatry staff to be respectful to psychiatry (77%). Psychiatry as a career choice: Out of 176 Interns who participated in the study, 23 (13%) Interns reported psychiatry as their career choice and 70 (40%) reported that they would “consider psychiatry” if their choice of specializations were not available for them. Discussion: To our knowledge, this is the first study from India to assess the attitude towards mental illness and psychiatry among Interns from minority (Muslim) Institutes. There have been studies on attitude of students/Interns towards mental illness and psychiatry all across the world for the past many years. Results from the studies are inconsistent with some studies (Alexander and Kumaraswamy, 1993; Balon et al., 1999; Baptista et al., 1993; Pan et al., 1990) showing that medical graduates had positive opinion regarding psychiatry, psychiatrist and treatment effectiveness while other studies found that students find psychiatry as emotionally draining, financially not rewarding, socially unacceptable and less scientific (Feifel et al., 1999; Soufi and Raoof, 1992). Some studies (Koh, 1990; Lampe et al., 2010; Tan et al., 2005; Qureshi et al., 2013; Lyons, 2014) found that clerkships, contact with faculty improved interest in psychiatry. 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 (Mino et al., 2001; Chew-Graham et al., 2003). However the evidence is inconsistent (Qureshi et al., 2013) on whether interest was maintained, with some studies indicating that the increase is transient. Some studies assessed the impact of psychiatric teaching program and clinical exposure on the attitudes of students. Two studies (Calvert et al., 1999; Gulati et al., 2014) found that the attitudes did not improve as students progressed through the course (after academic exposure), however another study (Yadav et al., 2012) have seen some improvement. The studies showing the impact of clinical exposure have not mentioned the attendance of the students in lectures/clinical postings. Our study found that less than 30% students have 75% (mandatory attendance for full fledged subjects) attendance in clinical postings / lectures and just over 25% students read major topics in

psychiatry. The reasons cited for low attendance included - preparation for pre term examination/semester examination, participation in college fest etc. This highlights the fact that the academic and clinical exposure can remain sub optimal with the present academic design and students might not consider psychiatry seriously. Our study found that attitude towards mental illness remains negative, with majority of the Interns considering mentally ill patients as dangerous, unpredictable, cannot take up major responsibilities, cannot be a good parent, have poor interpersonal or social skills. This is in line with the study by Yadav et al., however unlike in that study, majority of the Interns were not afraid of the people suffering from psychological disorder and did not consider them likely to be criminals. The attitude towards psychiatry overall, functioning of a psychiatrist, efficacy of psychiatry treatment was found to be good in over 90% of the Interns. They considered psychiatry a valid branch of medicine, making good progress in the research and felt that it is an upcoming field of medicine. About 70 % disagreed that psychiatry is unscientific and imprecise. The findings are better than earlier studies (Lingeswaran, 2010; Rajagopal et al., 2004; Soufi and Raoof, 1992) however 30% considering it as unscientific is still is a significant figure. Majority (90%) had a positive opinion on the treatment efficacy which is in line with the recent study (Lyons and Janca, 2015). The attitude towards career and reward aspect of psychiatry was not very favorable, with around 40% having a negative opinion, considered psychiatry as having low prestige, were uncomfortable with mentally Ill patients, and were discouraged by friends and family from entering psychiatry. Though this is similar to earlier studies (Lyons and Janca, 2015; Xavier and Almeida, 2010; Alexander and Kumaraswamy, 1993) the findings may be interpreted as less favorable, as majority of respondents in our study were females from a private medical college and studies (Khan et al., 2008; Gat et al., 2007; Al-Ansari and Alsadadi, 2002; Malhi et al., 2002; Tharyan et al., 2001; Aslam et al., 2009) show that female graduates /from private medical college have a more positive attitude of psychiatry. Career choice of Psychiatry: This study found that 13% Interns have psychiatry as their career choice and 40% would “consider” psychiatry as their career if they do not get into specialty of their choice. Our results are in line with recent studies (Aslam et al., 2009; Laugharne et al., 2009; Jain et al., 2014). A multicentric study across 20 countries (Farooq et al., 2014) also found similar response from Indian students. Our results are not in line with studies (Budd et al., 2011; CurtisBarton and Eagles, 2011; Gowans et al., 2009; Pailhez et al., 2005) that show psychiatry was preferred by < 5 % respondents, and two other studies (Tharyan et al., 2001; Abramowitz and Bentov-Gofrit, 2005) that show Psychiatry as preferred career choice. The one by Tharayan et al., found that 20% chose Psychiatry and the other study by Abramowitz and Bentov-Grofit, found that 32.8% of students chose psychiatry as their career. The study by Tharyan et al., was conducted in an attachment setting different from our study. It was done in a Christian Minority Institution in India, a private medical college, with sub specialty services providing training to post graduates in psychiatry. Also it included students from first to final years apart from Interns. Study by Abramowitz and BentovGofrit, included only preclinical students and the same cohort in another study (Gat et al., 2007) witnessed a marked decline in the interest during their clinical years, with results similar to our study. The reason for the observed variation across the studies could be due to differences in the, a) amount of academic and clinical exposure of the students to psychiatry – Increased exposure improves the attitude (Lampe et al., 2010;

Tan et al., 2005; Mino et al., 2001; Chew-Graham et al., 2003; Qureshi et al., 2013; Lyons, 2014); b) the attachment setting of the institution - private medical colleges students have positive attitude (Qureshi et al., 2013; Aslam et al., 2009); c) the year of the student while recruiting into the study (Yadav et al., 2012; Gat et al., 2007) and d) the percentage of female respondents (Baptista et al., 1993; Khan et al., 2008; Gat et al., 2007; Al-Ansari and Alsadadi, 2002; Malhi et al., 2002; Tharyan et al., 2001). Our study has included only Interns because studies have shown that the attitude of students change over the course. Also Interns can better report their interest and commitment to a particular career as they are at a critical stage in deciding about their medical specialty. Though the general opinion about psychiatry, psychiatrist and treatment efficacy was good, the negative opinion about mental illness, discouragement by the family members, and the unfavorable attitude towards the social and reward aspects of psychiatry could be the reasons for less Interns showing interest in psychiatry as career. The reasons for continued negative opinion about mental illness seem to be due to the suboptimal academic exposure. These calls for a immediate relook into the current medical education as well as health policies. The current study assumes furthermore significance with the recent decision of MCI ‡ (Medical Council of India, via e-Gazette dated 03/07/2015) to reduce the minimum standard requirement of faculty (especially in psychiatry) for a medical college, at a time when studies have shown that contact with faculty improved interest in psychiatry among the students. To address the social reward aspects, a campaign to reduce stigma among general public is the need of the hour. General hospital psychiatry units should be strengthened with special focus on Consultation Liaison psychiatry to reduce stigma among other medical professionals. To ensure optimal exposure to psychiatry, attendance for Psychiatry lectures and postings may be made mandatory. Psychiatry may be made an independent specialty or at least a mandatory part of medicine examination. Alternatively the weightage for psychiatry in MBBS examination as well as post graduate entrance examination must be increased. The study is conducted in Muslim minority institutions with predominantly female graduates and the results cannot be generalized. Future studies with a big sample size with equal representation of gender and cultural background in other attachment settings are required, to look into the factors influencing career choice of the students. Acknowledgements: We greatly appreciate Dr. Md Sarib Rasool Khan, our Inst. Director, for his support in conducting the research

‡

Medical Council of India

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Table 1: Academic exposure to psychiatry Attendance /Preparation

Psychiatry lectures - n(%)

Clinical postings n(%)

Exam Preparation - n(%)

<25 %

66 (37.5)

50 (28.4)

38 (21.6)

25-50%

45 (25.6)

28 (15.9)

43 (24.4)

50-75%

32 (18.2)

45 (25.6)

48 (27.3)

>75%

33 (18.8)

53 (30.1)

47 (26.7)

Table 2: Dangerousness subscales of BMI Scale Item

Completely disagree – N (%)

Strongly disagree N (%)

Disagree N (%)

Agree N (%)

Strongly agree N (%)

Completely agree N (%)

A mentally ill person is more likely to harm others than a normal person. Mental disorder would require a much longer period of time to be cured than would other general diseases. It may be a good idea to stay away from people who have psychological disorder because their behaviour is dangerous Mentally-ill people are more likely to be criminals

7 (4)

6 (3.4)

30(17)

101(57.4)

14(8)

18(10.2)

41(23.3)

28(15.9)

13(7.4)

6(3.4)

34 (19.3) 125 (71)

22 (12.5)

69(39.2)

36 (20.5) 51(29)

9 (5.1)

6 (3.4)

I am afraid of people who are suffering from psychological disorder because they may harm me

34 (19.3)

17 (9.7)

68(38.6)

42(23.9)

7(4)

8(4.5)

Dangerousness 43 (24) 8 (4.5)

133 (76) 7(4)

27(15.3)

42 (24) 24(13.6)

134 (76) 24(13.6)

77(43.8)

125 (71)

119(68)

65(36.9)

32(18.2) 51 (29)

57 (32)

Table 3: Poor Interpersonal and social skills subscales of BMI Scale Item

Completely disagree – N (%)

Strongly disagree N (%)

Disagree N (%)

Agree N (%)

Strongly agree N (%)

Completely agree N (%)

The term ‘‘Psychological disorder’’ makes me feel embarrassed

34 (19.3)

22 (12.5)

62 (35.2)

37 (21)

8 (4.5)

13 (7.4)

A person with psychological disorder should have a job with minor responsibilities

5(2.8)

Poor Interpersonal and social skills 118 (67)

58 (33) 7 (4)

20 (11.4)

32 (18) I am afraid of what my boss, friends, and others would think if I were diagnosed as having a psychological disorder

19 (10.8)

It might be difficult for mentally-ill people to follow social rules such as being punctual or keeping promises

12 (6.8) 67 (38) 41 (23.3)

I would be embarrassed if people knew that I dated a person who once received psychological treatment

99 (56.3)

24 (13.6)

21(11.9)

18 (10.2)

21(11.9)

29 (16.5)

13 (7.4)

19 (10.8)

8 (4.5)

144 (82) 19 (10.8)

37 (21)

75 (43)

62 (35.2) 101(57)

19 (10.8)

36 (20.5)

20 (11.4)

51 (29)

112 (64)

67(38.1) 119 (62) 37 (21) 64 (36)

person with psychological disorder is less likely to function well as a parent

12 (6.8) 66 (37)

16 (9.1)

38 (21.6)

79 (44.9) 110 (63)

16 (9.1)

15 (8.5)

I would be embarrassed if a person in my family became mentally ill.

53 (30.1)

28 (15.9)

67 (38.1)

18 (10.2)

4 (2.3)

6 (3.4)

18 (10.2)

8 (4.5)

23 (13.1)

20 (11.4)

12 (6.8)

7 (4)

148 (84) Mentally-ill people are unlikely to be able to live by themselves because they are unable to assume responsibilities

19 (10.8)

28 (16) 17 (9.7)

45 (25.6)

81(46) Most people would not knowingly be friends with a mentally-ill person.

12 (6.8)

95 (54) 15 (8.5)

32 (18.2)

79 (45) I would not trust the work of a mentally-ill person assigned to my work team.

14 (8)

69 (39.2)

74 (42) 117 (55)

15 (8.5)

52 (29.5)

81 (46)

76 (43.2) 95 (54)

Table 4: Incurability subscale of BMI Scale Item

Completely disagree N (%)

Strongly disagree N (%)

Disagree N (%)

Agree N (%)

Strongly agree N (%)

Completely agree N (%)

8 (4.5)

12 (6.8)

23 (13.1)

86 (48.9)

30 (17)

17 (9.7)

Incurability Psychological disorder is recurrent

43 (24) Individuals diagnosed as mentally ill will suffer from its symptoms throughout their life. People who have once received psychological treatment are likely to need further treatment in the future.

133 (76)

25 (14.2)

20 (11.4)

51 (29)

47 (26.7)

19 (10.80

14 (8)

96 (54) 7 (4)

14 (8)

35 (19.9)

80 (46) 79 (44.9)

28 (15.9)

13 (7.4)

17 (9.7)

56 (31.8)

21(11.9)

17 (9.7)

10 (5.7)

22 (12.5)

28 (15.9)

13 (13.1)

28 (15.9)

63 (35.8)

12 (6.8)

5 (2.8)

56 (32) I do not believe that psychological disorder is ever completely cured. The behaviour of people who have psychological disorders is unpredictable. Psychological disorder is unlikely to be cured regardless of treatment.

29 (16.5) 102 (58) 6 (3.4) 38 (21) 31 (17.6) 122 (69)

120 (68) 36 (20.5) 74 (42) 87 (49.4) 128 (79) 37 (21) 54 (31)

Table 5: Scores on the Attitude towards psychiatry scale Item

Strongly disagree N (%)

Disagree N (%)

Agree N (%)

Strongly agree N (%)

Overall Merits of Psychiatry Psychiatric research has made good strides in advancing care of the major mental disorders

4 (2.3)

9 (5.1)

101 (57.4)

62 (35.2)

Psychiatry is a rapidly expanding frontier of medicine

3 (1.7)

13 (7)

163 (93) 21 (11.9)

24 (14) Psychiatry is unscientific and imprecise

54 (30.7)

Psychiatric Consultation for medical or surgical patients is often helpful Psychiatric treatment is helpful to most people who receive it

5 (2.8)

67 (38.1)

17 (9.7)

22 (12)

96 (54.5)

61 (34.7)

18 (10) 0

16 (9.1)

157 (90) 115 (65.3)

45 (25.6)

91(51.7)

4 (2.3)

27 (15.3)

Among mental health professionals, psychiatrist have the most authority and influence

7 (4)

160 (91)

69(39.2)

28 (15.9)

70 (39.8)

41 (23.3)

117 (67)

43 (24.4)

72 (40.9)

7 (4)

91 (51.7)

37 (21)

128 (73) 92 (52.2)

45 (25.5)

6 (3.4)

51(29) 88 (50)

145(82) 34(19.3)

101 (57.4)

79 (45)

125 (71) 57 (32.3)

3 (1.7)

144 (82)

97 (55)

33 (18.7)

13 (7.4) 16 (9)

48 (27)

Psychiatry is too analytical, theoretical and psychodynamic, and not attentive enough to patients physiology

65 (36.9)

17 (9.7)

With few exceptions, clinical psychologists and social workers are just as qualified as psychiatrists to diagnose and treat emotionally disturbed persons

Psychiatry is too biologically minded and not attentive enough to patients personal life and psychological problems

89 (50.6)

1(0.6)

32 (18)

Psychiatrist are too frequently apologetic when teaching psychiatry

9 (5.1)

154 (88)

160 (91) Most Psychiatrist are clear logical thinkers

46 (26.1) 55 (31)

16 (9) III Role Definition and functioning of psychiatrist Psychiatry is not a genuine and valid branch of medicine

63 (35.8)

152 (86)

121 (69) II Efficacy If someone in my family was very emotionally upset and the situation did not seem to be improving, I would recommend a psychiatric consultation

89 (50.6)

24 (13.6)

7 (4)

31(28) 83 (47.1)

44(25) 58 (33)

14 (7.9)

Table 6: Scores on the Attitude towards psychiatry scale (continued) Item

IV Possible abuse and social criticism Psychiatrists frequently abuse their legal power to hospitalize patients against their will On average, psychiatrist make as much money as most other doctors V Career and personal reward Psychiatry has a low prestige among the general public Psychiatry has high prestige among other medical disciplines Many people who could not obtain a residency position in other specialities eventually enter psychiatry Psychiatry is a discipline filled with international medical graduates whose skills are of quality My family discouraged me from entering psychiatry Friends and fellow students discourage me from entering psychiatry If a student expresses interest in psychiatry, he or she risks being associated with a group of would- be psychiatrists who are often seen by others as odd, peculiar or neurotic I feel uncomfortable with mentally ill patients VI Specific medical school factors Teaching of psychiatry at my medical school is interesting and of good quality During my psychiatry rotation, psychiatry residents were good role models Attending psychiatrists during my psychiatry rotation were good role models

Strongly disagree N (%)

Disagree N (%)

Agree N (%)

Strongly agree N (%)

51(28.9)

83 (47.1)

33 (18.7)

8 (4.5)

134 (76)

41 (24)

14 (7.9) 60 (34)

46 (26.1)

92(52.2) 116 (66)

24 (13.6)

35 (19.8) 91 (52) 14 (7.9) 70 (40) 32 (18.1)

56(31.8)

64 (36.3) 85 (48) 84 (47.7) 106 (60) 53 (30.1)

21 (11.9)

56 (31.8) 73 (41.4)

105 (60) 5 (2.8) 38 (22) 51 (28.9) 112 (64) 53 (30.1) 119 (68) 38 (21.5)

22 (12.5) 18 (10.2)

71(40) 33 (18.7) 61 (34.6) 66 (37.5) 65 (36.9)

103 (58)

111 (63) 138 (78) 44 (25) 66 (36) 44 (25) 57 (32) 54 (30.6)

27 (15.3) 20 (11.3) 13 (7.3) 19 (10.7)

73 (42)

28 (15.9) 103 (58)

75 (42.6)

57 (32.3) 73 (42)

16 (9)

16 (9)

23 (13)

89 (50.5)

48 (27.2)

39 (22) Does not apply 11 (6.2)

Most psychiatrists at my medical school are clear logical thinkers Most nonpsychiatry and house staff at my medical school are respectful of psychiatry

40 (23) 8 (4.5) 28 (16) 11 (6.2) 41 (23)

Although I am interested in psychiatry, no effort was made to encourage my becoming a psychiatrist at my medical school

25 (14.2) 110 (63)

137 (78)

29 (16.4) 20 (11.3) 30 (17) 85 (48.2)

96 (54.5) 136 (77) 115(65.3) 148 (84) 112(63.6) 135 (77) 42 (23.8) 65 (37)

40 (22.7) 33 (18.7) 23 (13) 23 (13)