Medical Students’

Attitudes

Toward Psychiatric Illness

Kenneth Duckworth, M.D.

Massachusetts Mental Health Center

Department of Psychiatry

Harvard Medical School

Constance A. Burke

Department of Sociology

University of Massachusetts/Boston

Russell K. Schutt, PhD.

Department of Sociology

University of Massachusetts/Boston

and

Department of Psychiatry

Harvard Medical School

Research funded by the National Alliance for the Mentally Ill

We are grateful for the assistance of Lois Mastrangelo

Introduction

A 32-question survey designed to assess first year medical students’ knowledge, experience and attitudes towards psychiatric illness was administered to 424 students from three medical schools in the fall of 1998. The survey was designed to inform medical training in a period when primary care doctors are often the first medical professionals to evaluate persons with psychiatric illnesses and to make decisions about referrals for further treatment. Of course, the results of this survey do not offer a representative sample of all first year medical students in the United States. Rather, the survey was meant to begin a dialogue between medical schools, mental health providers and mental health advocates.

The medical student survey included questions about the respondents’ knowledge, personal experience, attitudes and help seeking behavior with regard to psychiatric and medical illness. The number of respondents from school A, B and C was 89, 121 and 214 respectively, representing more than 90% of the first year class at each school. Some comparisons are made between the results garnered from this sample and those obtained in a random sampling of 400 Massachusetts residents asked the same questions in a 1997 survey (Opinion Dynamic Corporation).

Of the 424 medical students surveyed, 47 percent were female and 66 percent were between the ages of eighteen and twenty-four. Thirty percent of the first year medical students were undecided when asked what their planned future specialty was going to be. Of those who did name a specialty, 37% chose primary care or family medicine, 18% selected pediatrics, 20% named surgery or a surgical sub-specialty and 3% listed psychiatry as their future specialty.

Knowledge

The knowledge section of the survey was comprised of seven question meant to test the medical students’ basic knowledge of psychiatric illness. Two additional questions about medical illness were included for comparative purposes. The knowledge questions were based on common facts that were thought to indicate the medical students’ initial knowledge of medical and psychiatric illnesses. The percentage of correct answers by medical students to the knowledge questions about psychiatric illness is used to indicate their basic knowledge. For two of the questions the medical students’ knowledge is compared to the results of the ODC survey of the general public in Massachusetts.

The questions answered correctly by the medical students most often (Table 1) were awareness of the possibility of significant improvement of schizophrenic illness (76%) and the implications of depression for heart disease (72%). The most frequently missed questions concerned knowing that split personality is not a feature of schizophrenia (41%) and the success rate of insanity pleas in felony cases (27%).

Table 1: Correctly answered questions about psychiatric illness

Knowledge About Mental Illness	Percent Answered Correctly
Significant improvement with schizophrenia rare	76%
Depression increases risk of heart disease	72%
Cycles of moon effect people w/ MI	67%
Treatment for MI equivalent to medical illnesses	52%
ECT considered unsafe and rarely used	52%
Split personality a feature of schizophrenia	41%
Insanity defense successful in felony cases	27%

There were only minor differences between the three schools in the percentage of correct responses to the various knowledge questions (Figure 1).

A ‘Knowledge of Mental Illness’ index was created for the percentage of correct answers to the set of seven knowledge questions about psychiatric illness. The scores form a normal distribution with a mean score of 57% (Figure 2). Two-thirds of the 424 medical students surveyed answered correctly less than 60% of the knowledge questions.

Students were asked to report on where they think they learned the most about psychiatric illness. More than one source of information or learning was accepted for this question. Undergraduate school and personal experience were the two most common sources of information about psychiatric illness for these medical students (table 2).

Table 2: Sources of knowledge of psychiatric illness

SOURCE OF Knowledge	Percent
Medical school	4%
Undergraduate school	43%
Personal experience	24%
TV and electronic media	13%
Print media	21%

Correct answers to two of the items from the ‘Knowledge about Psychiatric Illness’ index were compared between the medical student sample and the 1997 ODC Massachusetts general public survey sample (figure 3). Medical students scored higher on both of these two items.

Personal Experience

Medical students were also asked if they had any personal experience with mental illness. Experience with mental illness included either the student having a mental illness or having a friend or family member who had suffered from a mental illness.

Table 3 lists the percentage of students who reported having firsthand experience with psychiatric illness either through a personal diagnosis or with friends or a family member. The students who reported having personally suffered from a mental illness represented 3% of the total number of medical students surveyed. Of the sample, 47% reported having a friend or family member who had a mental illness. The general Massachusetts public, in the ODC survey, reported a comparable amount of personal experience with psychiatric illness: 6% had suffered from mental illness themselves and 44% acknowledged having a friend or family member who had suffered from a mental illness.

Table 3: Personal experience with psychiatric illness

personal experience	Percent
Respondent suffered from a psychiatric illness	3%
Friends or family members suffered from a psychiatric illness	47%

Attitudes

In assessing medical students’ opinions about psychiatric illness, questions were asked about the use of slang terms in reference to the mentally ill and the equity of treatment for psychiatric illness versus medical illness. Table 4 lists the percent of students who agree, disagree or have a neutral opinion about these issues. The high percentage of students who disagree that slang terms like “crazy”, “psycho” and “wacko” are harmless indicates an awareness of the derogatory nature of these commonly used terms.

Half of the medical students disagreed that psychiatric patients receive the same medical care as others. The response to this question is of interest when taken in conjunction with that of the knowledge question regarding efficacy of treatment for psychiatric illness versus medical illness. About half of the medical students disagreed that psychiatric patients receive the same medical care as others and answered incorrectly when asked the question on efficacy of treatment for psychiatric illness versus medical illness. These medical students believed that psychiatric patients not only receive different medical care than others, but that the psychiatric care they receive is unequal to their medical care.

Table 4: Use of slang terms^*1, and equality of care^*1

opinions Towards Treatment in Medical Culture	Agree	Neutral	Disagree
Psychiatric patients receive same medical care as others.	20%	33%	47%
Slang terms are common in medical culture.	10%	14%	76%
Slang terms are harmless.	4%	1%	95%

The distribution of students from each school who agree with these statements is presented in Figure 4. Only a small percentage of students from each of the three medical schools included in the study agreed that slang terms are harmless to people with psychiatric illness.

Help Seeking Behavior

In assessing medical students’ help seeking behavior the same questions were asked with regard to heart disease and mental illness. Students were asked how likely they would be to seek treatment for the two conditions named. Table 5 compares the likelihood medical students' would seek treatment for heart disease and psychiatric illness. Almost all of the respondents indicated they would be very likely to seek treatment if they suspected they were experiencing symptoms of heart disease, while only 46% would do the same in the case of a psychiatric illness. This disparity suggests there is greater reluctance or a perceived decreased need to obtain professional care when suffering from a mental illness.

Table 5: Medical student to seek treatment for heart disease or for a psychiatric illness.^*2

Likelihood to seek treatment	very likely	somewhat likely	not likely
If thought had heart disease symptoms	98%	2%	0%
If thought had mental illness symptoms	46%	40%	14 %

Students were also asked how likely they think a person would be to tell their employer about their condition whether that condition is heart disease or a mental illness. Almost all of the students responded by saying that a person was not likely to tell their employer about a mental illness (table 6).

Table 6: Perception of likelihood person will disclose to employer had heart disease or had a psychiatric illness.^*2

Likelihood to tell employer	very likely	somewhat likley	not likely
If had heart disease	42%	36%	22%
If had a mental illness	1%	6%	93%

These same questions were asked of the ODC general population sample. The distribution in Figure 5 shows the percentage of respondents for the medical students and the general public who would seek treatment for heart disease and psychiatric illness and also the number who would tell their employer about these same conditions. Although over 90% of the respondents in each group reported they would be very likely to seek treatment for heart disease, there was a difference between the medical students and the general population in regard to the likelihood they would seek treatment for a psychiatric illness. About 25% more of the respondents in the general population than among medical students reported they were very likely to seek treatment for a psychiatric illness.

Discussion

The purpose of this survey of first year medical students at three medical schools was to obtain a “biopsy” of the knowledge, attitudes and experiences about psychiatric conditions they bring to their education. It was thought that the results could inform educational efforts in medical instruction.

On questions of knowledge, students bring substantial areas of misunderstanding about psychiatric conditions and treatments to their schooling. Many students endorse popular myths about schizophrenia, ECT, and the insanity defense, and a substantial minority endorse a myth about bipolar illness. A substantial minority lack information about the role of depression in heart disease, the course of schizophrenia, and efficacy of medication in psychiatry. Students did do better than the general public survey on several myths in psychiatry.

One half of students report knowing someone with a psychiatric condition, including the 3% who have a psychiatric condition themselves. Students report the most common source of information about psychiatric illness is undergraduate school followed by personal experience, print media and electronic media. Students indicate more learning from formal education and less from TV than other population surveys.

Students show a clear pattern of differentiating psychiatric illness from heart disease in terms of seeking help and determining whether a person with these conditions would tell his/her employer. These are findings that may have implications for how doctors advise and create access to psychiatric treatment as opposed to treatment for heart disease. Notably, many students believe people with psychiatric illness do not receive the same level of care as non-psychiatric patients.

These findings have implications for medical education in relation to people with psychiatric illnesses. Knowledge deficits, endorsement of popular myths, and an aversion to seeking help for psychiatric conditions as compared to “medical” conditions all point to a substantial need for thoughtful interventions that could include curricula, exposure to people with psychiatric conditions, and mentoring/modeling in medical education.

Further study could include a comparison of interventions involving medical schools with different educational approaches, or following a cohort of students to discern the effect of medical socialization toward psychiatric illness.

Footnotes:

1. Agree = response choice (1) strongly agree, (2) agree; Neutral = response choice (3) no opinion; Disagree = response choice (4) disagree, (5) strongly disagree.

2. Very likely = response choice (1) absolutely certain, (2) very likely; Somewhat likely = (3) somewhat likely; Not likely = response choice (4) not likely, (5) definitely not.