- Top of page
Aims: The aim of the present study was to explore medical students' beliefs and attitudes towards people with schizophrenia (PwS) prior to receiving any training in psychiatry and to assess the impact of the psychiatric placement on changing them.
Methods: A questionnaire addressing beliefs, attitudes and desired social distance from PwS was distributed to all final year medical students before the beginning of their 4-week undergraduate psychiatric placement and upon its completion.
Results: Students did not endorse stereotypes commonly attached to PwS, such as being dangerous, lazy or of lower intelligence, but they held the view that PwS are unpredictable and suffer from split personality. Furthermore, the baseline level of desired social distance was found to increase as the intimacy of the interaction increased, and the only variable associated with it was personal experience of serious mental illness. Moreover, the placement was found to have either no influence at all or in a negative direction. Upon its completion more students were found to believe that PwS cannot recover, have no insight into their condition, cannot make reasonable decisions, cannot work in regular jobs and are dangerous to the public. No difference was recorded in social distance scores.
Conclusions: A close and critical examination of the various elements of the undergraduate placement in psychiatry is needed in order to develop an evidence-based, fully rounded education with an anti-stigma orientation.
THE STIGMA AND prejudice surrounding mental illness exist widely throughout the world. Public surveys have shown that the general population has limited knowledge about mental illness and holds unfavorable attitudes towards the people who suffer from it in various, culturally diverse, countries.1–3 Nonetheless, stigmatizing attitudes to mental illness, and especially schizophrenia, the most representative of the psychiatric disorders in lay people's minds,4 are not limited to the general population but are also common among health professionals.
Many surveys have shown that medical doctors endorse stereotypical views and negative attitudes towards patients with psychiatric disorders.5,6 This finding has also been validated by first-person accounts of people with mental illness. Focus group studies have found that when service users were asked about their stigma experiences and about potential groups for targeted anti-stigma interventions, family doctors were the group most often mentioned,7 with service users reporting that health-care providers treated them disrespectfully, they had to wait longer than other patients and that their physical complaints were not taken seriously.8 In addition, various studies have indicated that stigma and discrimination by physicians often lead to people with psychiatric disorders having less access to primary care,9 and receiving inferior care for physical health problems, such as heart attacks,10 despite the high rates of physical illness and mortality among them.11,12
It is thus imperative to develop effective strategies for improving physicians' attitudes and practices towards people with mental illness. One of the strategies that has been proposed is that of targeting medical students, who are considered ‘tomorrow's doctors’.13 A cohort study in England demonstrated that while 28% of medical students reported that people with psychiatric disorders are not ‘easy to like’, 2 years later, when students had become medical practitioners, the rate increased to 56%.14 Furthermore, a wealth of studies worldwide has shown that medical students hold rejecting and distancing attitudes towards people with mental illness.15–17 These negative misconceptions not only impact on people with psychiatric disorders and their families, they also damage the image of psychiatry, because the majority of medical students show diminished interest in pursuing it as a career,18 with subsequent shortages of psychiatrists globally. Consequently, it seems of paramount importance to explore and ultimately alter the inaccurate knowledge and unfavorable attitudes towards people with mental illness in this particular group.
The role of undergraduate psychiatric placement has been emphasized as the means of inducing change in medical students' stigma endorsement. Prior to any formal training in psychiatry, medical students share the same beliefs and attitudes as the general population.17,19 During the psychiatric placement, however, students have the opportunity to advance their knowledge about mental illness and to closely interact with people who suffer from it. According to this rationale, undergraduate training in psychiatry is expected to reduce stigma and discrimination, and empirical evidence supports this effect,20–22 although some studies have yielded contradictory results.15,23 This discrepancy in the literature can be ascribed to the variability of undergraduate psychiatric training courses across countries, in spite of continuous efforts on the part of the World Psychiatric Association (WPA) to standardize it. As a result, undergraduate psychiatric training is of central interest for an anti-stigma program, because its curriculum integrates two effective strategies for fighting stigma and discrimination: education and contact with psychiatric patients.24
In Greece, a national study on lay beliefs and attitudes towards patients with schizophrenia has found that the general population is more rejecting and distancing towards people with schizophrenia in comparison to the general population in Germany and Canada.2,25 Similarly to the general population, equally stigmatizing attitudes have been expressed by non-psychiatry physicians, who have been constantly complaining about the treatment of patients with severe mental illness in general hospitals. Congruent with this and building upon previous work, the Greek “Anti-Stigma” Program, run by the University Mental Health Research Institute, conducted an investigation into stigma endorsement in medical students within the framework of the WPA ‘Open the Doors global program against stigma and discrimination because of schizophrenia’. The study explored medical students' beliefs, attitudes and desired social distance towards people with schizophrenia (PwS) and assessed the impact of undergraduate psychiatric education in changing them. To achieve these aims a pre/post-test design was followed, similarly to other studies on the same topic.6
- Top of page
The present study had the twofold aim of investigating medical students' beliefs, attitudes and desired social distance from PwS prior to receiving any formal training in psychiatry as well as of evaluating the effect of the psychiatric placement in improving them. Concerning the former aim, the present data suggest that medical students hold complex views about PwS, some being favorable and some not. Similarly to the views held by the general population in Greece2,25 as well as in other countries,1 medical students perceive PwS as being unpredictable, shouting in city streets and being incapable of making their own decisions. Nonetheless, in sharp contrast to the beliefs held by lay people, the majority of students reported that PwS can work and are not dangerous. A possible explanation for this difference between medical students and the general population might lie in the characteristics of the present sample. Medical students were young, they had a high level of education and more than half of them reported knowing someone with serious mental illness. All three variables have been found to constitute correlates of favorable attitudes towards people with mental illness.1 Personal experience of psychiatric disorders in particular increases one's familiarity with mental illness, which in turn leads to decreased level of perceived dangerousness.29 This might be a plausible explanation of why the majority of medical students did not perceive PwS as being dangerous.
The pattern of results is similar for social distance. Consistent with the findings of the national survey of attitudes towards PwS in Greece,2,25 the social situations that evoked the most rejecting responses on the part of medical students were those of marrying and sharing a room with a PwS. Many studies have shown that the general population expresses a high degree of desired social distance for social encounters of high intimacy.3,30 It is noteworthy that although the majority of students did not perceive PwS as being dangerous, nonetheless, they would not visit a hairdresser who was afflicted with schizophrenia. This negative reaction might be mediated by endorsement of the unpredictability stereotype. Students might feel wary of exposing themselves to a situation with an ambiguous outcome, not falling in their realm of control. Alternatively, it highlights the importance of bearing in mind social desirability bias when enquiring about beliefs pertaining to PwS. When students were directly asked about PwS being dangerous, they disagreed with the item; nonetheless, when they were indirectly asked about it via the germane social distance item, they displayed some endorsement of the stereotype.
Gender and experience of serious mental illness were the factors that appeared to exert some influence on students' baseline attitudes and desired social distance. Specifically, women appeared slightly more stigmatizing than men, but the differences between the two genders were not substantial. This finding is consistent with other studies that have pointed towards this lack of effect.30,31 In contrast, personal experience was found to play a prominent role, especially with regard to social distance scores, in agreement with other studies in the field.30,32
Regarding the second aim of the current study, the undergraduate psychiatric training was found to have had either no effect at all, or in a predominantly negative direction. It did improve certain perceptions, but these were positive already (e.g. that schizophrenia is not the outcome of poor parenting and is not a contagious disease). In addition, it did correct to a large extent the misconception stemming from the literal etymology of the word ‘schizophrenia’ (i.e. split mind in Greek) that PwS suffer from split personality. Nonetheless, its impact was predominantly negative. While the majority of students at the beginning of the study endorsed the view that PwS can work and are not dangerous, the majority changed their mind at follow up. Similar aggravations were observed in items addressing the potential of PwS for recovery, their insight into their condition, their ability to make reasonable decisions and their deteriorating course of illness. In addition, the undergraduate training in psychiatry did not succeed in challenging fundamental stereotypes, such as that PwS are a public nuisance (no difference before and after training). Similarly, no differences were seen in social distance items and composite scores as a result of the placement, a finding consistent with other studies on the topic.15,23 This is not surprising, given that it follows the worsening of beliefs and attitudes after the training.
To explain the absence of a positive impact of the placement, in spite of integrating two of the most effective strategies for fighting stigma and discrimination, that of contact and education,24 one should look into the characteristics of the undergraduate psychiatric training course. The psychiatric placement had a short duration, 4 weeks only, and took place in psychiatric hospitals and psychiatric departments of general hospitals. Students had contact with patients who were acutely ill or who suffered from serious and chronic psychiatric disorders. As a result of this, they were not given the opportunity to extend their experience of PwS in the context of community or rehabilitation services. There, medical students would have interacted with PwS who had never been hospitalized and who were successfully treated in the community as well as with patients who continued their treatment outside the hospital. Medical students' one-sided clinical experience may have contributed to the negative influence of the placement, because there is evidence that the acute phase of schizophrenia creates significant stigma, whereas knowledge about after care reduces it.33 For this particular reason it has been suggested that students' experience should not be confined to interacting with inpatients and outpatients, but it should also entail encountering patients who have recovered or are in the process of recovery.34 Furthermore, being in close proximity and assuming partial responsibility in such severe cases after only 2 weeks of lectures, might not have allowed sufficient time for medical students to assimilate the information and to acquire the necessary skills for managing these patients. This in turn might have intensified their emotional reactions to PwS, and promoted stigma.
Because the curriculum of undergraduate psychiatric training in Greece did not entail any specific anti-stigma training modules, one could argue that the present findings advocate for incorporation of such an orientation in undergraduate psychiatric training. Future work in this direction might shed light on the significance of such an education. An undergraduate training course in psychiatry that is anti-stigma oriented, might act as an evidence-based anti-stigma intervention that would be embodied in the curriculum and therefore become an integral part of routine teaching in psychiatry. Such a training course should provide medical students with a well-rounded clinical experience of patients with schizophrenia, while allowing them to observe closely some patients' course of illness from acute treatment to rehabilitation in the community. In addition, prior to bringing into contact medical students with patients, it should allow sufficient time for students to assimilate the information conveyed during lectures and to work on their own emotions about patients. In addition, such a training course should be delivered by mental health professionals who have reflected on their own attitudes towards patients with schizophrenia and who can subsequently relay positive messages about them in their teaching.
Finally, the present study was not without its limitations. The Beliefs and Attitudes section of the instrument was analyzed on an item level, because the reliability analysis and the correlation matrix showed that analysis on a scale level was statistically inappropriate, casting in this way important doubts on the psychometric properties of the particular section. In addition, only medical students from the main medical school in Athens were recruited and therefore the findings cannot be extrapolated to all medical students in Greece. Furthermore, participants were not followed up some years after completion of their medical training to investigate which of these beliefs and attitudes were sustained.