Assistant Professor of Family Medicine
Erciyes University Medical Faculty
Department of Family Medicine
Tayfun Turan, MD
Associate Professor of Psychiatry
Erciyes University Medical
Department of Psychiatry
Dr. Selcuk Mistik
Erciyes University Medical Faculty
Department of Family Medicine
TR-38039, Kayseri, Turkey
Phone: +90-352-4374937 (23851)
Objectives: To determine
the opinions and attitudes of first and final
year medical students towards mentally ill patients;
to compare the attitudes of the two groups to
see the effects of medical education and confronting
of the patients, and to evaluate the stigmatization
of the mentally ill by future medical professionals.
Methods: A questionnaire
comprising 19 questions regarding opinions and
attitudes towards mental illness was administered
to the first and final year medical students.
Results: There were 308 students
who filled out the questionnaire, which was 81%
of the total of the first and final year students
(n = 388). Observation and talking were the most
common preferred choices in both of the groups,
for recognizing a psychiatric patient (First year
55.1%; Final year 70.8%). The final year students
felt more indifferent, less fear, and less compassion
when they saw a psychiatric patient.
Conclusions: It appears that
there is stigmatization of mentally ill patients
even among medical students, which could be decreased
with the addition of lessons on stigmatization
of mentally ill patients and more social intercourse
with the patients.
Key Words: mental illness; medical
students; attitudes; stigmatization
The one-year prevalence
of any psychiatric disorder was reported as 28.1% in
the USA. The one-year prevalence for some of the mental
illnesses are as follows; unipolar major depression
5.0%, panic disorder 1.3%, schizophrenic/schizophreniform
disorders 1.1%, cognitive impairment 2.7%, any alcohol
disorder 7.4%, any substance use disorder 9.5%. The
lifetime prevalence rates of these diseases are almost
twice the one-year prevalence (1). In recent years,
there has been a revolutionary change in the systems
of care and treatment devised for mentally ill patients
that has involved a movement away from institutional
care, towards greater involvement in the community (2).
An increased need for the rehabilitation of mentally
ill subjects was prompted by the worldwide movement
of deinstitutionalisation. Individualized rehabilitation
must be in mutual interaction with the social and occupational
The objective of rehabilitation
is to enable the patients after their recovery, to acquire
their former social and occupational status and to help
the disabled and handicapped to achieve the maximum
in health, work competence, occupational and social
integration and quality of life (3). However, numerous
studies show the persistence of negative attitudes of
the public towards the mentally ill. In spite of the
insertion of psychiatry in the community, stereotypes
and stigmatization of psychiatric patients did not change
accordingly (4,5). An important gap exists between the
beliefs of the population and present psychiatric knowledge
(4). Studies about population attitudes towards mentally
ill show that people are afraid of mentally ill patients,
would not employ them, would not marry them, would not
establish any relationships with them, and mentally
ill patients are considered as violent (6).
Stigmatization of mentally ill patients has negative
effects in their rehabilitation. In this regard, the
attitudes towards mentally ill patients, especially
the attitudes of health professionals, which might play
a major role as a model to public attitudes, could be
a major factor in defining the quality of the future
life of the mentally ill. The aim of this study was
to determine the opinions and attitudes of first and
final year medical students towards mentally ill patients,
and to compare the attitudes of the two groups to see
the effects of medical education and confronting the
patients, and to evaluate the stigmatization of the
mentally ill by future medical professionals.
The study was carried out during May 2003,
in Erciyes University Medical School, Kayseri, Turkey.
There are 40 medical schools in Turkey, and Erciyes
University Medical Faculty is one of the oldest schools,
which was founded in 1968. Kayseri is a trade center
in central Anatolia, and has a population of 536,000.
A questionnaire comprising 19 questions
was designed by using the structure used by former studies
regarding the attitudes towards mentally ill (7,8).
The questionnaire was administered to the first and
final year medical students. There were 204 first year
and 184 final year medical students, and there were
1,281 students in total in the medical school. The duration
of medical education is six years. The first year medical
students have 42 hours of psychology (behavioral sciences)
lessons. The third year medical students have 15 hours
of psychiatry lessons. The fifth year medical students
have 18 days of psychiatry clerkship with 45 hours of
lessons. The final year medical students are studying
at psychiatry wards and clinics for one month.
The questionnaire was collected
immediately after it was filled out. There was no information
given to the students about the diseases in order not
to affect the current points of view of the students.
The names of the students were not written on the questionnaire
in order to make the students feel comfortable in filling
out the form.
There were 308 students who filled
out the questionnaire. The response rate was 81% of
the total group. One hundred and forty seven were first
year and 161 were final year medical students. Of the
first year students, 43.5% (64/147) were female and
56.5% (83/147) were male. Of the last year students
50.3% (81/161) were female and 49.7% (80/161) were male.
The mean age of the study group was 22.4 ± 2.8.
The questionnaire consisted of two
parts. The first part had thirteen general questions
about the attitudes towards mentally ill patients (Table
1) (7). In the second part of the questionnaire, eight
opinions about six mental illnesses: severe depression,
panic disorder, schizophrenia, dementia, alcohol disorder,
and any substance use disorder were asked (Table 2)
The questionnaire was administered
to five first year and five final year medical students
to perform a pilot study. No change in the questionnaire
was required due to the results of this study. The questionnaire
was administered to both of the years at the end of
the year when the lessons of the first year students
were completed and the last year students were about
to complete their studies at the psychiatry department.
Medical students who are members of 'the scientific
research group of psychiatry' delivered the questionnaire.
The sample can be considered representative of the students
of our medical schools, however we cannot say that the
group represents all of the medical students in Turkey.
Statistical analysis was performed
using SPSS statistical package (Version 11.0, SPSS Inc.,
Chicago, Il, USA) for Windows. Chi-square tests were
used to determine the differences between the groups.
The level of statistical significance was set at p <
The last year students
met and talked with psychiatric patients more than the
first year students (Table 3). The difference of answers
about recognizing a psychiatric patient was statistically
Observation and talking were the most common preferred
choices in both of the groups for recognizing a psychiatric
The final year students felt more indifferent
(17.5%), less fear (5.6%), and less compassion (13.1%)
when they saw a psychiatric patient (p<0.001). Most
of the students of both groups tended to continue their
relationships with a friend who had a psychiatric disease.
There was no statistically significant difference between
the choices of marrying a psychiatric patient of the
two groups, where 91.6% of the first year and 88.0%
of the last year medical students do not want to marry.
Most of the first year (71.4%) and the final year (74.3%)
medical students thought that psychiatric patients could
hurt someone. In both of the groups (first year and
final year students), hospitals (15.6% vs. 12.5%), care
houses (19.0% vs. 5.0%), together with the other people
(25.1% vs. 28.7%) and multiple choices (23.1% vs. 32.5%)
were stated for places psychiatric patients should live.
The final year students would give a job to a mentally
ill patient, more than the first year students (p =
0.030). There was a difference as well between the students
who knew a psychiatric patient and the other students,
in giving a job, where the ones who knew such a patient
would give them a job with a higher percentage (p =
0.009). The percentage of students who said that they
did not hesitate in examining a psychiatric patient
was not statistically significant.
In a question where
multiple choices could be marked, the first year medical
students mainly thought that psychiatry patients were
strange (22.4%), unforeseeable (24.4%), strange and
unforeseeable (25.8%). The final year medical students
also thought that these patients were strange and unforeseeable
(18.6%), and unforeseeable (31.0%). Seventeen first
year students (11.5%) and 30 (18.6%) of the final year
students defined psychiatric patients as 'like everyone
else'. Forty-seven (31.9%) of the first year medical
students stated that the causes of psychiatric diseases
are due to life experiences, 43 (29.2%) due to genetic
factors and life experiences, and 34 (23.1%) to both
genetic factors, life experiences and organic reasons
(multiple choices could be marked). The final year medical
students evaluated the causes of psychiatric diseases
as: 94 (58.3%) due to genetic factors, life experiences
and organic reasons, 20 (12.4%) to genetic factors and
life experiences, and 13 (8.0%) to genetic factors,
life experiences, organic reasons and other reasons.Ten
(6.8%) students from the first year and 11 (6.8%) students
from the final year evaluated the causes as life experiences
and organic factors.
When the diseases were
separately evaluated, there were more differences between
the first and last year students on evaluating mentally
ill patients (Table 4). The final year students stated
that patients suffering from severe depression as less
'dangerous to others', more 'unforeseeable', 'blame
themselves' more, and 'can take care of themselves'
less. The opinions of the two groups are almost totally
different for panic disorder, where the final year students
stated that they were less 'dangerous/aggressive', more
'unforeseeable', not 'hard to communicate', 'blame themselves'
less, 'can take care of themselves' more, and 'harm
themselves' less. The evaluation of schizophrenia patients
was very different as well, where the final year students
thought that they were more 'dangerous', 'harder to
communicate', 'can take care of themselves' less, 'never
cured' more, and 'harm themselves' more. The differences
were less in the evaluation of dementia, alcohol disorder,
and any substance use disorder. The final year students
thought that dementia patients 'blame themselves' less,
'could take care of themselves' less, and 'not cured'
more. The only difference for alcohol disorder was that
the last year students thought that they 'blame themselves'
more. For any substance use disorder, the final year
students thought that they are more 'unforeseeable',
and 'blame themselves' less.
It was an expected
result to see that the final year students knew, met
and talked with psychiatric patients more than the first
year students, due to the medical school curriculum.
The final year students felt more indifferent, less
fear, and less compassion when they saw a psychiatric
patient. When the diseases were separately evaluated,
there were more differences between the first and last
year students on evaluating mentally ill patients.
There are some limitations
in this study. The first limitation of this study was
not to administer the same questionnaire to the same
student group after 6 years training. The second limitation
was that the demographic properties of the study groups
were disregarded, because the main aim was to see the
changes caused by the education given throughout the
medical school years. General questions on mentally
ill patients were not separately asked for neurotic
patients and psychotic patients in order to compare
the results with the present literature data.
Although there are
studies regarding the attitudes towards mentally ill
patients (4-8), we could not find a study on the attitudes
of medical students. Blizard has found no differences
in the attitudes towards the mentally ill patients between
university students and the rest of the community (9,10).
However, it is possible to expect some differences with
the attitudes of the community and the medical students,
especially the final year students.
Vezzoli et al. have
reported in a community study 52%-70% who have talked
with psychiatric patients and 21%-45% who often meet
with psychiatric patients (7). This is compliant with
the final year students' percentage, which declare that
they frequently meet and talk with psychiatric patients.
It has been reported
in various studies that family therapy is better than
conventional treatment and individual therapy when relapse
rates are considered (10-12). In our study group, we
could not get satisfactory answers about deinstitutionalisation
of the psychiatric patients. This is probably due to
the ideas of students that psychiatric patients are
dangerous/aggressive, not cured with treatment, which
Vezzoli et al. have
reported that students and the unemployed would give
psychiatric patients a job (86%), whilst the self-employed
were less willing (57%) (7). In this study, last year
students would give a job compliant with the self-employed
(Table 3). This may not be attributed only to negative
opinions whilst some of the patients cannot actually
Crisp et al. have reported
in a community study that 62% of the respondents rated
people with severe depression as hard to talk to, 19%
responded that they could pull themselves together,
23% that they would not eventually recover, and 23%
that they are dangerous to others, yet only 16% thought
that they would not respond to treatment (8). In this
study, the medical students think that it is harder
to communicate with patients suffering from severe depression,
probably because they have to take a detailed history
of the patient. The ideas of the medical students about
being not cured are less (First year: 9.8%, final year:
8.8%) when compared with the 16% in Crisp et al.'s study.
It is possible to say that social intercourse and more
work experience with psychiatric patients have made
a change in how the final year students feel about the
patients. Feeling indifferent and having less fear can
be considered as a positive change in the evaluation
of the patients from the point of view of doctor-patient
relationship. Having less compassion for a patient can
be unimportant as a medical professional, but this must
not lead to disregarding and bad manners towards the
patient, and loss of empathy for the patient.
Objection of marrying with a psychiatric patient cannot
be considered as stigmatizing the mentally ill patients,
but a normal manner for protecting themselves. Some
of the psychiatric patients can be dangerous and aggressive
during the course of the disease, but this does not
mean that they are always dangerous and aggressive.
This condition must not lead to the stigmatization of
It might be expected
to see that none or nearly none of the final year students
would hesitate to examine a psychiatric patient. Confronting
the mentally ill patients has made the final year students
think that less of the patients are strange, but more
of them are unforeseeable. We might expect to see more
of the final year students stating that psychiatric
patients are like everyone else, but probably due to
considering only the psychotic patients, there is no
difference between the two groups for this item.
It is possible to say that medical education changes the
opinions and attitudes of medical students in a positive
way. For many mentally ill persons stigma has emerged
to be a 'second illness' (4). Health professionals can
also stigmatize psychiatric patients. Nevertheless, there
are still some obstacles in the approach to the psychiatric
patient, like hesitation of the examination of psychiatric
patients. There is stigmatization of psychiatric patients
among medical students as well as there is in the community,
which could be overcome with more frequent social intercourse
among the medical students and the psychiatric patients.
According to the results of this study, it might be an
effective intervention to insert lessons regarding the
stigmatization of the patients into the medical curriculum.