ATTITUDE TOWARDS PSYCHIATRY--A COMPARATIVE STUDY AMONG MEDICAL INTERNS AND UNDERGRADUATE STUDENTS OF A TERTIARY CARE HOSPITAL IN KERALA.
The stigma connected to mental disease and mentally ill is a universal phenomenon and a serious barrier to provision of mental health services.  Stigmatising attitudes toward mental disease does not lie solely among uninformed members of a society; they exist among health professionals, as well as medical students, which they carry onto their professional lives. [2-5] Global recruitment in psychiatry has been falling for many decades as a result of medical students and graduates are finding it consistently unattractive. [6,7] Medical students have misperceptions regarding psychiatry, even before they start graduate school. The factors that appear to deter medical students from taking over psychiatry as a future career might include: stigma, bad prognosis of psychiatric illness, lack of scientific rigour in psychiatry, psychiatrist's low status among physicians, threats of violence from patients and lack of resources. [6-11]
The potential impact of psychiatry clerkships throughout undergraduate medical training on student attitudes and career alternative has been extensively studied largely at academic establishments in developed countries.  Many previous studies have found that medical students undertaking psychiatric internship do develop a lot of positive attitudes toward psychiatry [13-15] though some studies have found no measurable change. [16-18] But some authors disagree and assume that undertaking psychiatric clerkship doesn't essentially change students' opinions to decide on to specialise in the subject [19,20] and that the improvement is temporary, with the proportion of potential candidates for psychiatry continue to fall up until the completion of graduate school. [21,22] When negative attitude towards psychiatric disorders have been reported to be prevalent in all sections of society,  it is not surprising that medical students carry with them these prejudices when they enter the medical community.  However, if these negative attitudes are overlooked and unchanged throughout the course of medical education, it may prove harmful in the longterm. 
Trend to settle on psychiatry as a career by doctors and their orientation towards management of psychological problem in physically unwell patients as general physicians and surgeons is demand of the current time. Maximum part of perspective building towards subjects takes place in medical coaching. Therefore, attitude of medical students is of paramount importance.  However, Psychiatry as a discipline is felt to be given a lukewarm treatment at the undergraduate level which is mirrored in the range of lectures in psychiatry and number of hours of Psychiatry clinical posting.  Until recently, even during the course of the internship, Psychiatry was considered to be a non-mandatory subject as compared to compulsory posting in Surgery, Medicine, Gynaecology, among other branches.  So as to improve psychiatric coaching within the undergraduate medical population both in terms of quantity as well as quality, the character and magnitude of shortcomings in information, perception, and attitude toward psychiatry in this cluster ought to be assessed and understood. [23,29] Previous analysis into attitude to psychiatry as a specialty and career choice appears to have produced conflicting results and most of it was conducted among medical students. 
Aim and Objectives
This study compared the attitude of the medical interns who had completed their psychiatry internship with that of the final year medical students who were yet to do the internship in Psychiatry. This was to determine the impact of the internship on the students' attitude to psychiatry. Additionally, study assessed medical students' attitude towards psychiatry as a profession and a choice of career after graduation.
1. Final year students who are yet to start internship
2. Interns who have completed their psychiatry internship
Students and interns who refused to participate
This hospital-based cross-sectional study was conducted in Academy Of Medical Sciences, Pariyaram, Kerala. The duration of study period was 1 month, conducted in August 2017. At that time, all interns completed their compulsory rotatory internship in Psychiatry for 2 weeks. The final year MBBS students were yet to start their internship in Psychiatry. Questionnaires were distributed to students who gave their informed consent for participation for study.
1. Sociodemographic data sheet
2. Attitude Towards Psychiatry questionnaire (ATP-29).
The authors designed a brief demographic and career interest questionnaire, which was used in obtaining data such as age, gender, academic year and preferred career choice following graduation.
The study used Balon et al's questionnaire which consisted of 29 questions which examined the attitudes of medical students towards psychiatry and explored six main areas: 1) overall merits of psychiatry 2) efficacy 3) role definition and functioning of psychiatrists, 4) possible abuse and social criticism, 5) career and personal reward and 6) specific medical school factors. The items are scored on a Likert scale with responses expressing the degree of agreement with the sentence described in each item: "strongly agree," "moderately agree," "moderately disagree," and "strongly disagree". Results "strongly agree" and "moderately agree" responses are combined; also "strongly disagree" and "moderately disagree" included in the study.
Data analysis done using the SPSS (version-20.0). Standard descriptive statistics (mean, median, standard deviation, percentage) were used to analyse the characteristics of participants. The differences between the final year students and interns were assessed using Chi-square test and p-value <0.05 considered significant.
Ethical clearance was obtained from institutional ethical committee.
Out of total 133 students, 38 did not give consent or returned the questionnaire back. A total of 95 participants was included in final analysis of the study, out of which final year medical students and interns were 42 and 53, respectively.
Overall, majority of the students from two groups had a favourable response to the statements of the ATP-29 scale. More positive attitude towards mental illness came from interns when compared to final year students in this study. This was true for majority of statements of scale used in the study. This could be attributable to the administration of the attitude questionnaire after two weeks of internship, which included seminars, lecture classes, case presentations, daily ward rounds and residential duty. A positive impact of psychiatric clinical postings, lectures, and workshops on attitude towards psychiatry had been reported in previous studies as well. [13,16,18]
In the present study, attitude towards overall merit of psychiatry was evaluated. Results were found to be equivocal in two groups when considering that psychiatric research has made a good strides in advancing care for major mental disorders. Majority of interns and final year students disagreed that psychiatry is considered unscientific and imprecise. In some studies, undergraduate students were found to believe psychiatry to be an imprecise, unscientific branch and did not believe it to be an expanding branch. [13,30]
Regarding psychiatric consultation and recommendation to other people who are emotionally disturbed, 100% interns agreed to this statement. However, another study reported negative opinion about seeking psychiatric consultation.  The statement 'psychiatrists to be having the most authority and influence among mental health professionals', more than half of final year students had contrast opinion. This may be due to lack of awareness and knowledge about this specialty in Indian students. [29,31] Overall, majority agreed psychiatry was scientific and the treatment was worth recommending to family members with psychiatric problems. This opinion is in contrast to that found in some previous studies that claimed lack of scientific rigour, and non-efficacy of treatment.
Regarding psychiatrist's role and functioning, "Psychiatry is not a genuine and valid branch of medicine," 19% of the final year students disagreed with this statement compared to interns (7.6%). The confusion regarding the role of clinical psychologists and social workers in interns persisted even after internship, as they were not able to differentiate their role in psychiatry. It could be due to underexposure of students to psychology during internship and poorly planned curriculum.
Students generally disagreed on views that psychiatrists misuse their powers to lock up their patients inside hospitals. Students may be aware about the mental health act, which prevents overruling the rights of the patients while a decision on hospital admission is considered.
Majority of the final year students felt that 'psychiatry' had low prestige among general public and other medical disciplines. They believed that psychiatrists are respected less in their society, and had prejudices of those choosing psychiatry as odd, eccentric people in their personality.
Around one-fourth of participants felt uncomfortable with mentally ill persons irrespective of exposure to psychiatry. This could be due their stereotype, negative perception of mental health care even before entering medical school.
A significantly greater agreement was reported by the final year (69%) as compared to the interns (24.5%) for the statement that no effort was made to encourage them to become psychiatrists at their medical school, which is alarming. Psychiatric training in the undergraduate medical curricula appears to be falling short, as reflected by an insufficient number of allotted lectures, shortage of qualified teaching faculty as well as inadequate clinical postings, which leads to inadequate exposure of medical students to psychiatry. [29,32]
Although, in the current study, there is better outlook of interns toward psychiatry when compared to final year students in some areas, their negative attitude cannot be ignored in few aspects of psychiatry which has to explored further.
Many of the students held positive opinions towards most variables assessing their attitudes to psychiatry, despite this observation; nearly none of them chose the profession as a choice of future specialisation. The 2 weeks duration of internship in psychiatry by medical interns very likely was not enough to have steered appreciable positive interest among them towards specialising in psychiatry. Some of the negative conceptions in the beliefs of medical students about psychiatry practice like 'not in the main stream' of medicine, and involves caring for patients without good treatment outcome, may contribute to their not choosing to specialise in the profession. Other factors that effect on specialty choices are personality characteristics.  Around 69% final year students and 32% of interns considered psychiatry profession as low prestige and less respected among general public, despite rating the discipline as having higher intellectual challenges than others. It is not surprising that despite having a favourable attitude to psychiatry, they were not interested in becoming a psychiatrist, suggesting that variables other than attitude determine specialty choice  like social stigma attached to psychiatry and low prestige among mental health care professionals.
Findings suggest that both groups do not have a negative attitude towards psychiatry in the study and they have a good perception of psychiatry, though they didn't show a significant change in their intention to pursue psychiatry as a prospective career.
The sample size was small, and study was limited to one medical college setting, so generalisation of results to other areas needs to be done with caution. Multicentric studies are required to assess the impact of current curriculum of psychiatry across various colleges.
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Sajad Mohammed (1), Yesudas Kalathara Francis (2), Binoo Divakaran (3)
(1) Junior Resident, Department of Psychiatry, ACME, Pariyaram, Kannur.
(2) Professor and HOD, Department of Psychiatry, ACME, Pariyaram, Kannur.
(3) Associate Professor, Department of Biostatistics, ACME, Pariyaram, Kannur.
'Financial or Other Competing Interest': None.
Submission 29-11-2017, Peer Review 23-12-2017, Acceptance 29-12-2017, Published 08-01-2018.
Dr. Sajad Mohammed, Nishad Dale, Umayanalloor P.O, Kollam, Kerala-691589.
Table 1. Descriptive Statistics of Age N Minimum Maximum Mean Standard Deviation AGE 95 21 26 23.85 0.850 Table 2. Distribution of Male-Female in the Sample No. of Students Percentage Male 22 23.2 Female 73 76.8 Total 95 100 Table 3. Frequency Comparison of Interns and Final Year Students No. of Students Percentage Interns 53 55.8 Final Year 42 44.2 Total 95 100 Table 4. Students' Attitude Toward Psychiatry Overall 20% chose Internal Medicine followed by OBG 18.9%. 11.9% each from final year students chose internal medicine and OBG respectively, while 26.9% and 24.5% of the interns chose Internal Medicine and OBG respectively as their preferred choice of specialty. Only 1.1% students out of both groups chose Psychiatry as a preferred area of future specialisation. 15.8% had no response and 17.9% of them were yet to decide regarding their future career of choice. Sl. ATP Questions Final Year (%) Interns (%) P-Value No. Agree Disagree Agree Disagree 1 Psychiatric 100 0 98.1 1.9 0.000 research has made good strides in advancing care of the major mental disorders 2 Psychiatry is a 85.7 14.3 98.1 1.9 0.114 rapidly expanding frontier of medicine 3 Psychiatry is 11.9 88.1 5.7 94.3 0.046 unscientific and imprecise 4 Psychiatric 88.1 11.9 100 0 0.008 consultation for an emotionally upset family member 5 Psychiatry is not 19 81 7.6 92.4 0.000 a genuine or valid branch of medicine 6 Psychiatrists 40.5 59.5 92.5 7.5 0.000 have the most authority and influence among mental health professionals 7 With few 26.2 73.8 58.4 41.6 0.000 exceptions, clinical psychologists and social workers are just as qualified as psychiatrists to diagnose and treat emotionally disturbed persons 8 Psychiatrists 9.5 90.5 7.6 92.4 0.000 frequently abuse their legal power to hospitalise patients against their will 9 Psychiatrists 33.3 66.7 60.4 39.6 0.001 make as much money as most other doctors 10 Psychiatry has a 69 31 32.1 67.9 0.000 low prestige among the general public 11 Psychiatry has a 40.5 59.5 71.7 28.3 0.018 high status among other medical disciplines 12 Family 21.4 78.6 37.8 62.2 0.027 discouraging from specialising in Psychiatry 13 I would feel 21.4 78.6 26.4 73.6 0.100 uncomfortable with mentally ill persons 14 No effort was 69 31 24.5 75.5 0.000 made to encourage them to become psychiatrists at their medical school P-value <0.05 considered significant Figure 1 Preferred Career Choice Percentage Undecided 17.9 No response 15.8 Others 4.2 Radiology 1.1 Dermatology 7.4 Anesthesia 2.1 Psychiatry 1.1 OBG 18.9 Surgery and allied 4.2 Specialties Pediatrics 7.4 Internal medicine 20 Note: Table made from bar graph.
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|Title Annotation:||Original Research Article|
|Author:||Mohammed, Sajad; Francis, Yesudas Kalathara; Divakaran, Binoo|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Jan 8, 2018|
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