|ORIGINAL RESEARCH ARTICLE
|Year : 2018 | Volume
| Issue : 1 | Page : 3-9
Attitudes toward mental illness among Caribbean medical students
Farid F Youssef
Department of Preclinical Sciences, The University of the West Indies, Trinidad and Tobago
|Date of Web Publication||14-Aug-2018|
Farid F Youssef
Department of Preclinical Sciences, The University of the West Indies, St. Augustine
Trinidad and Tobago
Source of Support: None, Conflict of Interest: None
Background: There are limited empirical data on all matters pertaining to mental illness in the Caribbean but what little there is suggests significant levels of stigmatization exist. In this context, health professionals reveal at least equal to or only slightly improved attitudes to mental illness as compared to the general population. In addition, while there is evidence of improved attitudes among the population at large over the past decade this trend has not been observed among health professionals. This study, therefore, sought to assess medical students' knowledge about and attitudes toward mental illness as they traversed medical school. Methods: Preclinical medical students were surveyed and then retested in their final year of training. Students completed a knowledge scale, and the medical conditions regard scale comparing attitudes to four mental illness and three physical illness.Results: Knowledge about and attitudes toward mental illness showed significant improvement over the 5-year period. However, both preclinical and clinical students revealed significant levels of stigmatization toward mental illness despite improvements in knowledge. Students recognized the need to prioritize treatment for persons with mental illness but did not want to be personally involved in the treatment process. Discussion: Results highlight that significant negative attitudes still exist among medical students toward mental illness and these persist up until graduation. There is a need for further research into innovations and interventions to address this matter.
Keywords: Caribbean, medical students, mental illness, psychiatry training, stigma
|How to cite this article:|
Youssef FF. Attitudes toward mental illness among Caribbean medical students. Educ Health 2018;31:3-9
| Background|| |
In 2001, the World Health Organization (WHO) in its report on mental health noted, that stigma is “the single most important barrier to overcome.” Indeed many persons suffering from mental illness describe stigmatization as being more life-limiting and disabling than the illness itself. Stigmatization has been linked to persons being ostracized from wider society with many members of the public believing that persons suffering from mental illness are responsible for their illness, that their illness is a result of a moral failing and that consequences of mental illness are that they are more prone to lying and violent behavior. Such attitudes often result in sufferers failing to gain meaningful employment and perhaps most important, result in a decreased willingness to seek professional help ultimately leading to poorer long-term outcomes. The situation is so insidious that these attitudes can often result in self-stigma, with persons adopting these attitudes themselves leading to low self-esteem and a downward spiral of negative life perspectives.
Against this background, the WHO report triggered national and global campaigns to eradicate stigma against mental illness. Examples of such initiatives are Opening Minds in Canada, the Time to Change Campaign in the United Kingdom and the National Mental Health Anti-Stigma Campaign in the United States. Such campaigns are slowly beginning to produce change as evidenced by the latest statistics from the UK which indicated that approximately 5% of the population have improved attitudes to mental illness over the past year (2013–2014). Data also suggests that the economic benefits of such campaigns outweigh their cost.
While there has been substantial progress among the public in the more affluent nations of the world, large sectors of global society in the developing world have not seen such dramatic gains., This is especially true within the Caribbean region where the plight of the mentally ill is not even a substantial part of the national conversation and as such less data are generally available. One recent report from the three largest Caribbean islands, Trinidad and Tobago, Barbados and Jamaica notes that knowledge concerning mental illness is low while stigmatization is especially prevalent against those suffering from schizophrenia or addiction. Another report from Jamaica confirms these findings despite gains that have been achieved by deinstitutionalization and development of mental health services within the wider community.
Unfortunately, while recent reports suggest improved attitudes among the general public toward persons suffering from mental illness in the more affluent nations are encouraging there is an increasing number of reports that highlight the fact that stigmatizing attitudes among medical personnel remain.,, The question if these attitudes are the same as the general public appears to vary from region to region, but perhaps most importantly, there does not seem to be much shift in the attitude of health professionals toward mental illness. Indeed, the very same report from the UK that revealed improved public attitudes found no change among health-care workers. Such findings have very real effects as evidenced by the report of the Disability Rights Commission in the UK indicating that persons with mental illness receive poorer physical healthcare which may lead to increased rates of premature death. Studies from South East Asia, Africa, Latin America, and the Caribbean all report high levels of stigmatization toward mental illness among health professionals.,,,,
Given these findings, it has been suggested that the very culture of medicine promotes stigmatization among health professionals and in turn, also prevents health professionals from seeking help for such illnesses. In this context, there has been a renewed focus on medical training and its role in shaping attitudes toward mental illness., While there is some evidence to suggest training and exposure to psychiatry clerkships may improve attitudes one of the limitations of many of the studies that have explored this issue in medical schools is that they have made use of cross-sectional data only.
In the Caribbean, there is a paucity of data regarding the attitudes toward mental illness among health professionals. It is estimated that on an average there are only two psychiatrists per 100,000 population and even fewer psychologists. By comparison data from the WHO indicates that there at least ten surgeons and ten obstetricians per hundred thousand population in most of the Caribbean region. In this context, it is not surprising that <5% of the total health-care budget in the region goes toward mental health services.
Recognizing the importance of changing this trend there is now significant interest in adapting the curriculum of medical students to reduce stigma and promote the consideration of psychiatry as a career choice. This study, therefore, sought to assess the attitudes of medical students in Trinidad and Tobago toward mental health illnesses during their preclinical years and also as they progressed through medical school. This serves as a first step toward understanding the state of stigmatization within the profession and the role of medical training in shaping these perspectives.
| Methods|| |
Ethical approval for this study was granted by the Faculty of Medical Sciences Ethics Committee.
The twin-island state of Trinidad and Tobago is the southernmost of the Caribbean archipelago of islands with a population of 1.3 million made up largely of persons of African and Indian descent with low proportions of persons of Chinese, Arab, and European descent. It is rich in hydrocarbons and enjoys a higher standard of living than most of its Caribbean neighbors, yet its level of national health care invokes much criticism from its citizens. The Government offers free health care through its public services, but service provision is highly variable, and those who can afford private treatment usually opt for it. According to its Ministry of Health website (http://www.health.gov.tt/sitepages/default.aspx?id=228) persons seeking treatment for mental health illnesses can access this either through one of six health centers that offer such services on selected days or the single mental health hospital, St. Ann's Hospital. While this hospital has worked hard to improve both its services and its image in recent years, it continues to be regarded negatively by the public at large as an institution where those who need to be are locked up. In this atmosphere, families hide loved ones who need real help because of the profound stigma attached to this need.
The University of the West Indies runs three medical schools in the islands of Trinidad and Tobago, Barbados, and Jamaica. The medical program at these schools is a typical undergraduate program in which students usually enter university soon after completing high school and undergo 5 years of training before graduation. The program in Trinidad and Tobago is divided into preclinical years (1 and 2) and clinical years (4 and 5) with the 3rd year (para-clinical) serving as a bridge year. During their 4th year of training, students spend 8 weeks in a psychiatry clerkship.
The present study sampled medical students at the University of the West Indies, St. Augustine Campus, Trinidad, and Tobago at two-time points over the period of their undergraduate study. Students were briefed before class and asked to voluntarily complete the survey instruments. It was clearly stated that no incentives would be given for participation, financial or otherwise and those who did not wish to take part were free to excuse themselves. Preclinical students were surveyed in 2011 and then testing was repeated with the same group of students during their final year of training in 2015. Due to a clerical error year two students surveyed in 2011 were allowed to graduate without repeat testing. No follow-up evaluations were done between their first contact in the preclinical years and the final survey in the year 5.
Instruments and scoring
Knowledge was assessed using a modified version of a previously validated instrument and one successfully used in our population. Students were presented with 18 statements and were required to indicate if they were true or false. Eight items were reversed scored to aid in the identification of indiscriminate answering. One point was scored for each statement correctly answered giving a maximum total knowledge score of 18. Statements used are listed in [Table 1].
|Table 1: Percentage correct responses to knowledge statements pertaining to mental illness|
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Attitudes toward the mentally ill were assessed using medical conditions regard scale (MCRS). This scale is a simple instrument that readily allows comparison between various medical conditions and has been shown to have good validity and test–retest reliability. We presented students with seven medical conditions, four pertaining to mental illness (schizophrenia, depression, alcohol addiction, and obsessive-compulsive disorder) and three physical illness (congestive heart failure, pneumonia, and meningitis). Each condition is followed by eleven statements to which students should agree or disagree by the use of a six-point Likert scale ranging from 1 = strongly disagree to 6 = strongly agree.
The eleven statements were as follows:
- Working with patients like this is satisfying
- Insurance plans should cover patients like this to the same degree that they cover patients with other conditions
- There is little I can do to help patients like this
- I feel especially compassionate toward patients like this
- Patients like this irritate me
- I would not mind getting up on call nights to care for patients like this
- Treating patients like this is a waste of medical dollars
- Patients like this are particularly difficult for me to work with
- I can usually find something that helps patients like this feel better
- I enjoy giving extra time to patients like this
- I prefer not to work with patients like this.
As can be seen, five items are negatively worded and thus reverse scored. Given these parameters, scores closer to six indicate conditions held in more positive regard, giving less evidence of stigmatization.
In addition, demographic information was collected including sex, ethnicity, religion, and information concerning whether participants knew someone with a mental illness. Students were not required to provide any identifying information and all data collected was anonymous.
Data were analyzed using SPSS software version 20 (IBM Corp, Armonk, NY). Means and standard errors were calculated for both the knowledge scale and the MCRS. Differences in means between preclinical students and clinical students were assessed using a paired t-test. All other differences were assessed using ANOVA and Tukey's test was used for post hoc analysis. In all cases, the a error was set at P < 0.05.
| Results|| |
The total number of students who completed the survey in 2011 was 245 (162 females) representing approximately 50% of the total population of medical students in the preclinical years. The average age of the students was 20.7 ± 0.2 years. In 2015, 114 (66 females) students were repeat tested representing approximately 65% of the year 5 clinical students; average age was 24.7 ± 0.3 years. Overall demographics are summarized in [Table 2] and are consistent with the demographics of the school.
Mental illness knowledge results
Eighteen questions were used to assess students' basic knowledge regarding mental illness. The mean score among preclinical students was 12.8 ± 0.1. There were no differences in scores between male and female students (P > 0.05) or between students who knew someone with a mental illness versus those who did not know someone with a mental illness (P > 0.05).
With respect to scoring on individual items three questions [Table 1] were answered incorrectly by more than 50% of the sample. In particular, the statement “Schizophrenia is a mental illness that involves multiple personalities” was correctly answered by only 20% of the sample; the statement “most people with severe forms of mental illness do not get better, even with treatment” was answered correctly by 49% of students and the statement “one in three persons will be affected with a mental illness in their lifetime” was correctly answered by 41% of persons. Two other statements “a person with bipolar (manic depressive) disorder acts overly energetic” and “people with mental illness tend to be violent and dangerous” were answered correctly by only over 50% of those tested. Taken together students seemed to have less knowledge about symptomology of mental illnesses and the extent of mental illness in the general population. This latter point is supported by the fact that 36% of subjects did not recognize the statement that “mental illness is a major global health problem” as being true.
Among clinical students tested 4 years later, mean knowledge scores were significantly higher when compared to preclinical students, 14.4 ± 0.2, P < 0.001. While there was again no difference between male and female participants in this group, there was a difference in scores between those who knew someone with a mental illness versus those who did not. The former group scored significantly higher, 14.9 ± 0.2 versus 13.8 ± 0.3, P = 0.006. As can be seen in [Table 1] clinical students' scores on the individual items were much higher than preclinical students on most of the items. The vast majority of clinical students (87%) recognized that mental illness is a major global health problem and all questions were answered correctly by more than 50% of the cohort.
Medical conditions regard scale
Among preclinical students, the combined mean score for mental illnesses (depression, schizophrenia, obsessive-compulsive disorder, and alcohol addiction) was significantly lower than that for physical illnesses (congestive heart disease, pneumonia, and meningitis), 43.2 ± 0.3 versus 53.1 ± 0.3, P < 0.001. In addition, as can be seen in [Table 3], students had higher scores for the three physical ailments suggestive of higher regard for treating such patients. Using ANOVA followed by post hoc analysis, the mean scores for congestive heart failure, pneumonia, and meningitis were all significantly higher than those for depression, schizophrenia, obsessive-compulsive disorder, and alcohol addiction, P < 0.05 [Table 4].
|Table 3: Medical Conditions Regards Scale scores among preclinical and clinical students four years later|
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|Table 4: Post hoc comparison of preclinical students' attitudes toward seven medical conditions|
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While there were no significant differences between the scores for the physical illnesses, schizophrenia, and depression were both seen in a more favorable light when compared to obsessive-compulsive disorder (OCD) and alcohol addiction (P < 0.01 in all cases). Knowing someone with a mental illness did not affect the scores on any of the seven illnesses tested except depression. In this latter case, persons who knew someone with a mental illness demonstrated more positive regard than those who did not (47.7 ± 0.7 vs. 45.4 ± 0.8; P < 0.05). Sex of students, ethnicity and religious affiliation did not significantly moderate the scores for any of the illnesses.
Among clinical students, there was also a significant difference between the mean attitude scores for mental illness, 46.2 ± 0.7 and physical illnesses 53.8 ± 0.7, P < 0.001. Again, as with the preclinical students, the scores for the three physical illnesses were all significantly higher than the scores for the mental illnesses, P < 0.001 [Table 3] and [Table 5]. Among the mental illnesses, alcoholism scores were significantly lower than the other three, P < 0.001.
|Table 5: Post hoc comparison of clinical students' attitudes toward seven medical conditions|
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When the attitude scores were compared between preclinical and clinical students, there was no difference in attitude as it relates to physical illnesses [Figure 1]. However, it should be noted that when the mean attitude scores for mental illnesses were compared clinical students displayed a significantly more positive attitude to these conditions than their preclinical counterparts, P < 0.001.
|Figure 1: Bar chart revealing attitude toward mental illnesses and physical illnesses among preclinical and clinical students. Despite a significant improvident in attitude toward mental illness among clinical students as compared to preclinical students (P < 0.05) both groups show less positive attitudes toward mental illnesses as compared to physical illnesses (P < 0.05)|
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| Discussion|| |
The study sought to explore stigmatizing attitudes toward persons suffering from mental illness among medical students in the Trinidad and Tobago as they progressed through their training. The first finding was that preclinical medical students reveal reasonable knowledge concerning mental illness, but they exhibit significant levels of stigma toward the mentally ill as compared to those suffering from other forms of illness. In particular, OCD and addiction were the conditions least likely to reveal a favorable response. These findings are perhaps not surprising and indeed are consistent with reports from other developing regions of the world including South-East Asia, the Middle East, and Africa.,,,
The use of MCRS to assess attitudes suggests that most of the young doctors in training appear to have little desire to pursue a career in mental health and such determinations are made very early during their career. It is little wonder then that a report from Trinidad and Tobago almost a decade ago noted that <5% of the 1st year students desired to pursue psychiatry as a career. Such attitudes toward careers in psychiatry are not confined to the Caribbean but further exacerbate the situation of the stigma that continues to abound within the region.
Further analysis of the individual questions within the MCRS revealed that students responded positively to questions concerning the importance of persons with mental illness receiving treatment and the need to invest equal resources in such conditions. Therefore, responses to statements such as “Treating patients like this is a waste of medical dollars” (disagree) and “Insurance plans should cover patients like this to the same degree that they cover patients with other conditions” (agree/strongly agree) demonstrate high positive regard and there was actually no difference in the responses on these questions between mental and physical illnesses. Questions in which students were required to work and engage in treatment of such individuals were generally negatively scored and demonstrated high levels of stigma. Thus, the overall attitude of the preclinical students seems to be to recognize the need and importance of treatment for the mentally ill but an unwillingness to engage in it themselves.
The exact reasons for this are unclear. It has been suggested that a lack of awareness and understanding of the mental health illnesses predisposes one to stigmatization. If this is indeed the case, one would expect medical training during which students are generally informed about mental health and spend 8 weeks participating in a psychiatry clerkship to improve attitudes. However, our findings do not support this. When the same group of students was assessed 4 years later in their final year of training, though there was some improvement, the stigmatizing attitudes were still very evident with mean scores falling significantly below those observed for physical conditions. This was although there was a clear improvement in knowledge scores as they pertain to mental illness.
The study findings support the work of Korszun et al. who also sought to assess attitudes to mental illness using the MCRS and also found stigmatization though it should be noted that this was a cross-sectional study. They too noted that medical training seemed to have little effect upon these attitudes with final year students revealing similar views as their 1st year colleagues. The reasons for these persistently negative attitudes are unclear, but their genesis may lie in the general negative stereotype that surrounds mental illness among health professionals that has already been described. This, in turn, is perhaps being transmitted to students unintentionally via the hidden curriculum. It has also been suggested that medical training can enforce stereotypes associated with mental illness as mental health professionals often spend most of their time working with the chronically ill and thus lose focus on those who recover and are quickly removed from treatment or discharged. This idea is supported by other work which reveals that attitudes are more negative among staff who work at in-patient facilitates as opposed to out-patient settings and also among staff who primarily deal with patients experiencing psychosis.
It should be pointed out that not all reports indicate a failure of training interventions as a means to reduce stigma. One report from Ireland described an improvement in clinical students' attitudes when exposed to a 6-week clerkship. Similar reports have emerged from Canada. However, the results of these studies are not quite so clear-cut. In the case of the Irish group, it should be noted that preclinical students exposed to a 9-week introductory course did not demonstrate improved attitudes. The authors attribute the success of the intervention among clinical students to the fact that it involved interaction with patients and working as part of the psychiatric team. Among the Canadian students, attitudes toward mental illness revealed improvements after the intervention but were still significantly poorer when compared to attitudes toward patients with Type II diabetes. These results, thus, suggest that while educational interventions may have some impact, there is still much to debate concerning the timing and nature of such initiatives as well as their overall effectiveness.
Taken together our results and the body of literature seem to suggest (i) undergraduate medical students demonstrate less positive attitudes toward patients with mental illness as compared to physical illnesses (ii) such attitudes show some improvement during training but despite improvements in knowledge are still significantly more negative when compared to physical illness and (iii) such attitudes may militate against medical trainees embarking on a career in psychiatry. This state of affairs is particularly concerning in an era when the number of mental illnesses is increasing, the current number of trained professionals in the developing world seeking to manage these conditions is woefully limited, and the numbers of professionals being currently trained to manage these conditions is static at best. It is worth noting that such realities are not confined to the developing world and that a recent editorial in the journal Academic Psychiatry  called for a reevaluation of the approach to the teaching and training of psychiatry stating “Addressing stigma must be undertaken, thoughtfully, rigorously, and explicitly, on every level—from academic leaders in the health profession at large, to psychiatric educators, to undergraduate and graduate trainees.“ While such a systematic overhaul appears necessary and is to be supported, governments in developing nations may need to consider including more short-term approaches to resolving such concerns, including but not limited to the provision of specific opportunities for the training of already practicing mental health professionals.
It is worth noting that these results should be considered in the context of certain limitations of the study. In particular, the response rate of approximately 50% among preclinical students indicates that half of the class was not represented. This rate rose to approximately 60% in the clinical years but as previously indicated these numbers were reduced because a cohort of students was allowed to graduate without retesting. Despite these numbers, it is worth noting that it is more likely that students interested in mental health illnesses would have been the ones to take part in the study and as such the results may, in fact, shed an overly positive light on the levels of stigmatization. A second limitation of this study is it only surveyed students from one medical school in the Caribbean. However, while there are over 20 “offshore medical schools” in the Caribbean that cater to international students (primarily the United States) only three associated with the University of the West Indies draw their intake primarily from the local population. In that sense even though only one school was sampled it represents a significant proportion of the Caribbean medical students undergoing training, the target demographic of this study. Also as all three schools are part of the UWI, the curriculum across schools is essentially the same.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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