Effects of a one-hour educational program on medical students' attitudes to mental illness
Correspondence address: YoshioMino Department of Social and Environmental Sciences, Graduate School of Medicine and Dentistry, Okayama University Graduate Schools, Shikata-cho 2-5-1, Okayama 700-8558, Japan. Email: firstname.lastname@example.org
Abstract A new 1-h educational program was developed to change attitudes towards mental illness, and was conducted on 95 first-year medical students in order to investigate its effects on their attitudes towards mental illness, using a pre- and postquestionnaire study design. A similar study without the program was conducted on 94 first-year medical students as controls. After the program, more students replied that they would accept former patients on relatively close social distance items. Favorable attitudinal changes were observed in terms of ‘psychiatric services’, ‘human rights of the mentally ill’, ‘patients’ independence in social life’, and ‘cause and characteristics of mental illness’. In contrast, no significant change was observed in the control group. These results suggest that attitudes towards mental illness could be changed favorably by this program.
Attitudes towards mental illness among the general population have been thought to be crucial in planning psychiatric services, and have also had effects on governmental policy regarding the mentally ill.1,2 When the mentally ill are discharged from a mental hospital and begin to live in a community, it is necessary for the general inhabitants to accept and support them as neighbors. Internationally, this has been recognized as crucial, and the World Psychiatric Association (WPA) started the WPA Global Program against Stigma and Discrimination because of Schizophrenia.
Mental health care in Japan has been hospital-centered and has been criticized internationally.3,4 However, the government amended the Mental Health Law in 1987, and community care for the mentally ill has been expected to develop.5 Therefore, attitudes towards mental illness should receive more attention in Japan by the government, the local authorities, mental health workers and researchers. Indeed, in Japan's new Mental Health Law, there is a description of the duties of the nation, and Article 2–2 states that
the nation shall endeavor to maintain and improve the collective mental health, to deepen its understanding of mentally disordered persons, etc., and to cooperate with the efforts of those suffering from mental disorders, etc., in overcoming their problems and endeavoring towards social rehabilitation6
and this article was newly formulated in the reformed law.
There have been a number of studies on attitudes towards mental illness in Japan.7–9 Machizawa et al. suggested that Japanese population were more intolerant of mentally ill patients than people from the USA.9 Therefore, favorable changes in attitudes have been the focus, and there have been some studies that have investigated the effects of mental illness education in medical students,10–12 nursing students,13 psychology students,14,15 and in the general population.16 In Japan, Mino et al. surveyed the effects of medical education on attitudes towards mental illness using cross-sectional and 5-year follow-up methods, concluding that the attitudes of medical students developed favorably through medical education.17,18 However, other studies have been unsuccessful in finding such favorable results.11,13,16
In order to change attitudes among citizens, briefer programs are required. Therefore, we developed a 1-h educational program, which intended to change attitudes towards mental illness favorably. The purpose of this study was to examine whether a 1-h educational program can change attitudes towards the mentally ill.
SUBJECTS AND METHODS
All 95 subjects were students who had entered Kochi Medical School in 1991. Seventy-one were male and 24 were female. Sixty-seven were under 20 years of age and 28 were 20 years or older. Four students had graduated from other universities before they entered the school. A 1-h lecture was conducted for the subjects in May 1991 and they had received no prior education on mental health or psychiatry in the school. In the lecture, Mino explained the characteristics of Japan's mental health and psychiatric services compared with those in England, such as higher in-patient rate per 10 000 population for mental illness, larger proportion of long-stay (> 5 years) in-patients, and a poorer social support system for the mentally ill in Japan.1 According to the governmental statistics, the number of in-patient had increased from the 1950s in Japan, while that in England had decreased since 1954. In contrast, the number of places for day care and residential care was larger in England. He presented the case of a schizophrenic patient living in a community, who had made use of various kinds of mental health and social welfare services including out-patient services, day-care services, nurse visits, social workers' consultation, and pension for the disabled. He emphasized the importance of the development of community services for the mentally ill, such as residential and day-care services and primary care, in order to improve the quality of life of the mentally ill.19 Difficult and specialized terms were avoided in the lecture. This lecture was part of the formal curriculum in health science for the first-year students, which consisted of 18 lectures.
The 94 controls were students who had entered Okayama University Medical School in 1999. Among them, 69 were male and 25 were female. Sixty-six were 19 years or younger and 28 were 20 years or older.
A questionnaire survey on attitudes towards mental illness was conducted before the lecture. The questionnaire consisted of the following items: (i) questions about the acceptance of the mentally ill graded by five social distances20 used for evaluating acceptance by social distance; and (ii) questions on attitudes towards mental illness, adopted from Japan's previous survey,7 including seven items about psychiatric services, two about the treatment of mental illness at early stages and prevention, six about the human rights of the mentally ill, six about the independence of patients in social life, and five about the characteristics and causes of mental illness. The same questionnaire survey was conducted after the lecture. Eighty-one (85.3%) students replied satisfactorily in the survey before the program and 79 (83.2%) in the postprogram survey. The same questionnaire surveys were conducted on the controls, before and after a lecture that had no relation to mental health. Seventy-two (76.6%) control students replied satisfactorily.
The effects of the 1-h education program were evaluated by comparing the responses of the first survey with those of the second survey, and by comparing the changes between the educational intervention group and the control group. To examine the statistical significance, two-tailed χ2 tests and two-tailed Fisher's exact tests were adopted.
Table 1 shows the results of the comparison of acceptance of former mentally ill patients classified by social distance. In the items concerning close relationships, such as ‘children's marriage’, ‘to rent a room’, and ‘to accept as coworkers’, there were more students in the intervention group who showed tolerant attitudes towards former patients in the second study than in the first study (P = 0.004–0.02). However, there were no significant differences between the percentages of favorable replies on the items that were relatively socially distant, such as ‘to accept as neighbors’ and ‘to accept as community members’. In the control group, there were no significant changes between the replies before and after the lecture.
Table 1. Changes in acceptance of a former mentally ill patient on five social distance items before and after the program
|Would you discourage your children from|
marrying former patients?
|If you had a room to rent in your home would you|
be willing to rent to former patients?
|Would you be willing to work on a job with|
|Would you object to having former patients|
|Would you be willing to have former patients|
join a community club or organization?
The comparison of the replies about attitudes towards psychiatric services before and after the education is shown in Table 2. Regarding the items such as ‘function of mental hospitals’, ‘openness of mental hospitals’, and ‘respect of patients’ opinion’, significantly more students in the intervention group replied favorably after the lecture than before (P = 0.0001–0.014), while no significant change was found between before and after the lecture in the control group. There were no significant changes in the proportions of replies about the two items concerning attitudes towards treatment of mental illness at an early stage and prevention, as shown in Table 2.
Table 2. Changes in attitudes towards psychiatric services and prevention before and after the program
| Mentally ill patients should be detained in a|
mental hospital which is remote from any
place of habitation.
| Mental hospitals are needed to prevent|
mentally ill patients from committing
violence and injuring others.
|Mental hospitals should be open.||Agree||37.0||67.1||< 0.001||36.1||50.0||NS|
| Opinion of patients should not be respected|
in terms of going out or staying out from
| Training for social life should be conducted in|
| Mentally ill patients should stay in mental|
hospitals all their life.
| Long-term in-patient life makes patients|
develop difficulties in living in a community.
|Early treatment and prevention|
| Mentally ill patients would recover if they|
had treatment at an early stage.
| Mental illness could be prevented by|
Table 3 shows the comparison of the replies before and after education concerning attitudes towards the human rights of mentally ill patients. In the items of ‘divorce with spouses’ and ‘right to vote’, significantly more students in the intervention group respected the rights of the mentally ill after the lecture than before (P = 0.005–0.011), while no change was observed in the controls.
Table 3. Changes in attitudes towards the human rights of mentally ill patients before and after the program
|When mentally ill patients are admitted to a|
mental hospital, their spouses should be
permitted to divorce them unconditionally.
|Mentally ill patients should not have children,|
in order to avoid hereditary handicaps.
|Patients in a mental hospital should not have|
the right to vote.
|Mentally ill patients would be stigmatized|
all their life.
|If you have a family member who is mentally|
ill, its becoming known is shameful.
|Mentally ill patients could be reliable friends.||Agree||65.4||78.5||NS||75.0||81.9||NS|
The results concerning attitudes towards mentally ill patients' independence in social life are shown in Table 4. In all the items except the item of ‘to work at a sheltered workshop’, significantly more students in the intervention group showed favorable attitudes showing respect for patients' independence in social and community life after the lecture than before: ‘self-administration of drugs’ (P = 0.016), ‘to live in a community, attending out-patient clinic’ (P < 0.001), ‘to live in a community with delusions and hallucinations’ (P = 0.001), ‘to live in an apartment by themselves’ (P = 0.003) and ‘self-help group’ (P = 0.034). No significant change was observed in the controls.
Table 4. Changes in attitudes towards mentally ill patients’ social life and characteristics of the disease
|Independence in social life|
| It is impossible for mentally ill patients to|
administer their own drugs.
| Mentally ill patients attending out-patient|
clinics could live in a community, if there
were an emergency unit.
| Mentally ill patients could live in|
a community, if they had delusions or
| Mentally ill patients could not work at a|
| It is dangerous that mentally ill patients live|
in an apartment by themselves.
| It is impossible to organize self-help groups|
for the mentally ill.
|Characteristics of mental illness|
| Mentally ill patients’ abnormal behavior is|
| Mentally ill patients are frightening|
because of unpredictable behavior.
| Mental illness is a kind of disease like|
diabetes, hypertension and heart diseases.
| Mentally ill patients’ behavior is|
| Anyone could become mentally ill in a|
As to attitudes towards causes and characteristics of mental illness, the results are shown in Table 4. Significantly more students in the intervention group replied favorably after the lecture than before to the items of ‘patients’ abnormal behavior being temporary’ and ‘patients are frightening’ (P < 0.001). There were no statistically significant differences in the percentages of favorable replies in other items between pre- and posteducation. No significant changes were found in the control group.
When we compared the proportions of favorable responses in the pre-lecture survey between the intervention group and the control group, there were no significant differences in the proportions between the groups.
In order to change attitudes towards the mentally ill favorably, some procedures have been proposed. Rabkin reviewed the studies on attitudes towards mental illness, and divided attitude changes through education into two categories: the first was attitude change through classroom training and practical experience, such as psychiatric training programs, including clinical experiences, and the second was attitude change through academic instruction.21 The present study is of the second type. Costin and Kerr14 conducted a questionnaire study using Opinion about Mental Illness (OMI)22 before and after an ‘abnormal psychology’ course, and found that the subjects became less authoritarian and less socially restrictive in their attitudes. Graham gave the OMI to students in introductory and abnormal psychology courses at the start and end of a 10-week term, and found that scores on the interpersonal etiology scale increased in both classes.15 Malla and Shaw, however, reported the effects among female nursing students of instructional and experiential training programs on perception, beliefs and opinions about mental illness, and they found no differences in the subjects’ attitudes towards the mentally ill.13 In short, some but not all studies have shown the effectiveness of academic instruction in changing attitudes towards mental illness. However, the academic instruction adopted in the previous studies was a psychology course, which required a relatively long duration. For example, in Graham’s study, the course lasted 10 weeks. In contrast, in the current study, only a 1-h lecture was conducted and the results suggest that a 1-h education could change the attitudes favorably.
As for practical experience, some researchers found favorable effects of clinical experience on attitudes towards mental illness and psychiatry among medical students,10,12 and others did not.11 In the future, we should develop educational programs including clinical practice for Japanese students, which are designed to change students’ attitudes favorably.
In Japan, people are thought to be less tolerant to the mentally ill than those in Western society.9 If students have less tolerant attitudes towards mental illness before education, attitudes might be likely to change following education. This might explain the results obtained in the present study.
Regarding questionnaires to measure attitudes towards mental illness, in the 1960s, mainly in the USA, questionnaires such as the Custodial Mental Illness Ideology (CMI)23 and OMI22 were developed. In studies in England, the Attitude to Psychiatry Questionnaire (ATP) was used.10–12 Wada and Hiraoka modified the scales to be more relevant to the current social situation in Japan, and they developed a questionnaire for Japanese subjects.7 Phillips developed a rejection scale by five social distances, and the questionnaire has been used for two decades.20 Therefore, in the present study, the questionnaires of Wada and Hiraoka and the Phillip’s scale were employed. However, the differences in the questionnaires might have affected the results.
As to acceptance of the mentally ill by five social distance items, in a 5-year follow-up study,18 a favorable change was observed in the items that indicate intermediate distance (e.g., ‘acceptance of the patients as coworkers’), while in this study favorable changes were observed in three socially close and intermediate items, such as ‘not to discourage one’s children from marrying former patients’, ‘to rent a room’ and ‘acceptance of the patients as coworkers’. This might suggest that there are differences between the 1-hour education and the 6-year medical education in regard to the acceptance of the mentally ill by social distance.
In the present study, the category in which the most favorable changes occurred was ‘attitudes towards mentally ill patients’ independence in social life’ (Table 4) with significant improvement in all the items except for one. In contrast, Mino et al. suggested that attitudes changed in a category concerning psychiatric services through a 6-year medical education.18 This discrepancy is probably due to the differences in the content of the education conducted. In fact, in the 1-h lecture, the lecturer emphasized that most mentally ill patients could live in a community independently with adequate medical and social support. In the 6-year medical education, lectures on mental health from the viewpoint of public health were given during fourth year, and clinical education, including psychiatric services, was given during the fifth and sixth years. The 5-year follow-up study seemed to detect more influence of clinical psychiatry than of public health, and, as a consequence, attitude change was observed mainly in the category of psychiatric services.
In the current study, the authors found that attitudes changed favorably because of the 1-h educational program. This suggests that this program can be conducted for the general population. Despite the importance of public campaigns in reducing the stigma to mental illness, there have been few reports of community campaigns. One of the reasons for this is the belief that community educational programs for the general population require a lot of effort and time. However, according to the results of the current study, a relatively short and simple lecture could be successful in reducing the stigma of mental illness.
There are some limitations of the present study. The questionnaire method has been used in previous surveys of attitudes towards mental illness and the method is considered to be established.21 There have been few studies of the validity of questionnaires, probably because it is very difficult to establish a measure for true attitudes. Although it was thought to be appropriate to use the questionnaire in the present study, research which tackles the validity of the questionnaires is required. The second limitation regards the maintenance of the attitude change after the 1-h education. It is not clear whether the favorable attitude changes after the lecture observed in the present study will be maintained for months or years. In this study, attitude change was evaluated by a pre- and posteducation questionnaire survey and the posteducation survey was conducted immediately after the lecture. In order to overcome this limitation, a follow-up study is necessary to determine whether the changes observed in the present study are still present months and years afterwards. Third, the subjects of the present study were first-year medical students and were perhaps more intellectually gifted and probably more interested in medical issues, including mental health, than the general population. This might mean that these subjects would be receptive to this type of education, and careful attention should be paid to the effects of similar education in the general population, considering the failure to change neighbors’ attitudes through a public educational campaign.20 Lastly, an educational program was conducted in 1991 and surveys for the controls were carried on in 1999. The difference in years when the surveys were conducted might have distorted the results. When we compared the proportions of favorable replies in the pre-education or pre-lecture surveys between the intervention and the control groups, the proportions of the controls were greater than in the intervention group in 25 out of 31 questions, although there were no significant differences. This might suggest that younger students have more tolerant attitudes towards the mentally ill than older students.
In conclusion, the present study demonstrated favorable attitude changes towards the mentally ill through a 1-h educational program. In order to develop psychiatric and mental health services in Japan, public acceptance of the mentally ill and understanding of them are clearly important. Further studies are required to confirm these findings and to improve the methods and content of the education.
The authors would like to thank Professor Inoue, Department of Neuropsychiatry, Kochi Medical School for thoughtful discussion.