Psychiatric clinical exposure and its impact on attitude towards psychiatry in undergraduate medical students

Background: The discipline of psychiatry, and psychiatry as a career option, have been negatively regarded by medical students for decades. Recent literature states that disability due to psychiatric disorders has been increasing and the global burden of mental illness ranks second. For effective health care to be delivered, it is crucial that health professionals are not hampered by prejudiced attitudes. This study aims to assess the attitude of medical students towards psychiatry. Materials and Methods: The responses of 70 medical students from ﬁrst year; who have not been exposed to psychiatry were compared with 127 ﬁnal year students; who have completed psychiatry clinical postings, using ATP30 questionnaire that assessed their attitude to psychiatry and their interest in pursuing psychiatry as career choice. Results: The overall attitude towards psychiatry did not differ between students before and after psychiatric education. Women were found to have signiﬁcant positive attitude towards psychiatry (p=0.007). Even though the overall scores did not show signiﬁcant change, we have observed that psychiatric education had signiﬁcant inﬂuence on the students with respect to the role of psychiatrist, psychiatric hospitals and the effectiveness of psychiatric treatment. Conclusion: Psychiatric education positively inﬂuences attitude of medical students towards some aspects of psychiatry but does not increase the number of students willing to pursue psychiatry as a career. It will be helpful if changes are made in psychiatric curriculum for undergraduates to meet current and future deal with psychiatric disorders.


Introduction
The burden of mental disorders has increased worldwide. Global burden of mental illness is estimated to be 32.4% of years lived with disability (YLD) and 13.0% of disabilityadjusted life years (DALY), thus placing mental illness on level with cardiovascular diseases. 1 According to current estimates of mental illness to total disease burden in India, mental disorders are known to be the leading contributor to years lived with disability (14.5%) and 4.7% of DALYs. 2 Attitudes of stigma towards patients with mental illness are known to be prevalent in health professionals and students. 3 The undergraduate medical students are found to have notable shortcomings in knowledge and attitude about psychiatric disorders, mainly in the initial years of course. 4 The discipline of psychiatry, and choosing psychiatry as a career option, have been negatively regarded by medical students for decades. Attracting medical students to specialize in psychiatry has been a considerable problem. 5 Negative attitude towards psychiatry was reported among medical students after psychiatry clinical rotation. 6,7 For effective health care to be delivered, it is crucial that health professionals are not hampered by prejudiced https://doi.org/10.18231/j.ijn.2020.051 2581-8236/© 2020 Innovative Publication, All rights reserved. 263 attitudes. Hence, this study aims to assess the attitude of undergraduate medical students towards psychiatry and the impact of psychiatric clinical exposure on the attitude.

Materials and Methods
This cross sectional study was conducted at a medical college after obtaining approval from Institutional Ethical Committee. Under graduate medical students belonging to first and final year were recruited for the study. The first year students did not have psychiatric theory or clinical exposure while the final year students completed their clinical postings and are exposed to theory classes. Sociodemographic characteristics were obtained from the subjects using a semi structured proforma developed in the department of Psychiatry which included age, gender, Rural/Urban background. In order to ensure anonymity they were instructed not to write their names on their response sheets. ATP-30 Questionnaire was administered on all the subjects.
The ATP questionnaire consists of 30 items and has been standardized and validated. 8 It covers 7 related attitudinal areas pertaining to psychiatric patients, psychiatric illness, psychiatric knowledge, psychiatrists, psychiatric career choice, psychiatric institutions and psychiatric teaching. Respondents are expected to express their agreement or disagreement to each statement on a 5-point Likert scale ranging from 1(agree strongly) to 5 (disagree strongly). Half the items are positively phrased and reverse scored. i.e., Score for the positively phrased items (question no. 4, 5, 9-12, 14, 15, 18, 20, 23, 25, 27-29) were reversed by subtracting the score from 6. The total score for each respondent is the sum of the scores on all 30 statements. Score more than 90 indicate a positive attitude towards psychiatry while score less than 90 indicate a negative attitude. A neutral ATP is indicated by a score of 90. Maximum score is 150 and minimum score is 30.

Statistical methods
Data was entered and analyzed by using SPSS 21. Descriptive statistics were done. Mann-Whitney U test was applied for finding significance as the variables were continuous and distributed non parametrically. p <0.05 was considered as statistically significant.

Results
Total Study population -n = 197 Main interpretations from the results are: Students who were yet to be exposed to psychiatry already had positive ATP score (mean score of first year students -105.5 ± 9.96).
Women students had more positive mean ATP score than men indicating that women have more positive attitude towards psychiatry.
Exposure to psychiatric theory and clinics did not significantly increase the mean ATP score as a whole. (mean score of final year students -104.93 ± 11.49).
But there was significant positive change pertaining to aspects of psychiatric illness, psychiatric hospitals and role of psychiatrists and psychiatric treatment.
Exposure to psychiatry did not increase the likelihood of choosing psychiatry as a career.
Disappointingly, Majority of final year students reported that psychiatric training did not increase understanding of medical and surgical patients and also reported that psychiatric undergraduate training has not been valuable.

Discussion
In the present study, women students had more positive mean ATP score than men indicating that women have more positive attitude towards psychiatry. Similar findings are seen in a study done in Pakistan, where higher proportion of female students had more positive attitude as compared to their male counter parts. 9 Results of our study were in accordance to the earlier studies, which also showed that even though the overall scores on ATP30 questionnaire did not significantly change with psychiatric exposure, there were few aspects of psychiatry which had positive influence on medical students. 5,[10][11][12] In the current study, there was significant positive change pertaining to aspects of psychiatric illness, psychiatric hospitals and role of psychiatrists and psychiatric treatment. Exposure of psychiatry did not increase the likelihood of choosing psychiatry as a career. Previous study reported that even though majority of the UG students and most of the interns had positive attitude toward psychiatry, very few students affirmatively indicated to choose psychiatry as a career choice and nearly 73% denied choosing psychiatry as a specialty. 13 Medical students' attitudes towards psychiatry may be positive, but choice of psychiatry as a potential career option is unpopular. 14,15 There are several studies from various parts of world assessing the attitude of medical students following undergraduate psychiatric exposure. However, some found positive influence while some found no measurable change. [15][16][17][18] The discrepancies in the results of various   studies might probably be due to differences in the measures used to assess the attitude of medical students, teaching methods, duration of exposure and the proportion of patients with good prognosis to which students are exposed. Stigma attached to psychiatric illnesses, familial pressure against the psychiatry as a career choice may be reasons for very few doctors preferring to specialize in psychiatry. 19 Literacy on mental health and the interaction with patients may have positive effects on reducing stigma 3 and there is the improvement on stigmatization scores as the students get more contact with mental health patients. 20,21 This suggests a greater need for in-depth exposure to psychiatry and various subspecialties of psychiatry along with integration of medical, surgical and psychiatry clinical teaching.
The main limitation of our study is we did not compare the attitudes of same cohort of students before and after psychiatry posting. A prospective study of a cohort of students at various stages of clinical exposure would be a better alternative.

Conclusions
Psychiatric education positively influences attitude of medical students towards some aspects of psychiatry such as psychiatric illness, psychiatric hospitals and role of psychiatrists and psychiatric treatment but does not increase the number of students willing to pursue psychiatry as a career. It will be helpful if changes are made in psychiatric curriculum for undergraduates to meet current and future requirement of medical professionals to deal with psychiatric disorders

Source of Funding
No financial support was received for the work within this manuscript.

Conflict of Interest
The authors declare they have no conflict of interest.