Stigma attached to mental illness is one of the major barriers to improving the quality of care for persons with mental health problems. It is important to make antidiscriminatory principles an inseparable part of education at all levels (¹). Several studies have proved that negative attitudes towards the mentally ill which existed prior to training may be corrected through the course of medical education (²—⁶). We attempted to document whether the undergraduate psychiatry program influenced attitudes of students towards patients with mental illnesses. The analysis of collected data was intended to be used for enhancing the psychiatry curriculum at the University of Ljubljana, Slovenia, so as to encourage the teaching of antidiscrimination in the future doctors’ training.

We designed a questionnaire with 13 statements characterizing the most common stereotypes of people with mental illnesses. To assess stigma among university students regarding a Slovenian cultural background and perceived common stereotypes, we chose statements that expressed discriminatory attitudes from the World Psychiatric Association’s stigma assessment instruments (⁷) and from the questionnaire of Schulze et al. (⁸) regarding the Slovenian cultural background and perceived common stereotypes among university students. The original format of the statements was preserved. The Cronbach’s alpha value of the questionnaire was 0.83; this can therefore be regarded as a scale of discrimination.

A second group of statements addressed the emotional reactions to the mentally ill, including feelings of fear, shame, tension, and alienation. The statements were evaluated by a 5-point Likert scale (1=completely agree, 5=completely disagree). Seventy-two students completed the questionnaire at the beginning and the end of their psychiatry studies. The setting was arranged in such a way as to prevent discussion of the questionnaire, which was distributed in paper form. All students completed the questionnaire. The mean age of students was 23 years, and there were 47 female and 25 male students. In the period between the two questionnaires, the students attended 30 hours of lectures and 75 hours of clerkship in psychiatry over a 1-year period. The psychiatry clerkship consisted of 2 weeks of practical psychiatric history-taking with different diagnostic groups of patients, followed by feedback of psychiatrists. All of the students had equivalent experiences in different hospital departments with comparable diagnostic groups of patients.

The t test for dependent samples was used in order to assess the differences between the first and the second results.

The study was approved by the Medical Review Board at the psychiatric hospital. The participation of students was anonymous and voluntary, hence their answers did not influence their academic performance.

After completion of their studies, the students considered the mentally ill to be less dangerous, but also less able. Other stereotypes did not change significantly. The feelings of fear, reluctance, and alienation towards this group diminished.

During the course of study in psychiatry, which was carried out mainly in the form of a clerkship with direct contact consisting of psychiatric history-taking, no particular change in viewpoints about people with severe mental illnesses was noted. These viewpoints remain prevailingly within the neutral sphere, somewhere between denial and acceptance of stereotyped statements, and reflect that the relatively short clerkship does not diminish their prejudice towards their patients’ disabilities, but actually reinforces it. This could be attributed to the fact that during practical work, students met the most severely ill patients, whose conditions required hospitalization. Nevertheless, the students’ perceptions of patients as being less dangerous give reason for optimism. Progress was also noted in the decrease in negative feelings of fear, reluctance, and alienation. This change could be attributed largely to direct patient contact, since the number of practical exercises significantly exceeds the number of lectures and students often miss lectures that are not compulsory. In order to decrease other stereotypes, it would probably be necessary to use other educational methods. It is suggested that the experience of meeting with competent and encouraging representatives of recovered patients would be beneficial.

The absence of a comparison group and follow-up are strong limitations of the research, as well as the fact that clerking took place in different clinical settings and with patients who were not diagnosed with a severe mental illness. This could be a source of bias, since students had a lot of contact with patients with depression and neurotic disorders, who are proven to be held in greater regard by medical students (⁹). Other confounding factors were not assessed, such as gender (¹⁰) and students’ previous and personal experiences with the mentally ill (¹¹).

Psychiatric education with lectures and psychiatric clerkship in a standard psychiatric setting have the power to decrease emotional barriers toward psychiatric patients but fail to eliminate most stereotypical beliefs, except for the myth about the mentally ill being dangerous.