Stigma associated with psychiatry and psychiatric education across several continents, sadly, is well documented in this issue of Academic Psychiatry. Physicians-in-training in Colombia (¹), Romania (²), Saudi Arabia (³), and Spain (¹) indicate that our field is viewed quite negatively. Whether it is the scientific rigor of psychiatry, the biological basis of neuropsychiatric diseases, the quality of our practitioners and our trainees, or the public perception of our patients, psychiatry receives low marks. Beyond these concerns, medical students without psychiatric training in Nigeria (⁴) say that psychiatric patients are unpredictable, incapable of holding public office, have lesser intelligence than other patients, and are ill due to supernatural factors.

This collection of papers offers a sobering story for psychiatric educators, particularly when taken from transnational and international training perspectives. Admittedly, they do offer some small hope as well—but this excellent set of early studies should awaken us to the obstacles we face when endeavoring to build a more robust global workforce capable of caring for people living with mental illness. In this commentary, I will highlight key findings of the manuscript set, emphasize the tremendous value of the authors’ efforts to build a common methodology for their empirical work, and point to a few challenges that we can see more clearly because of this collection.

Harsh attributions toward trainees in or approaching psychiatry are among the more dramatic results in this collection. For instance, as shown in Table 1, many respondents in Saudi Arabia (82%), Romania (52%), Colombia (38%), and Spain (22%) endorse the observation that medical students risk being perceived as "odd, peculiar, or neurotic" if they express interest in psychiatry. The desire to enter psychiatric training was criticized and discouraged by family (e.g., 82% of respondents in Saudi Arabia) and friends or colleagues (e.g., 47% of respondents in Romania) and not encouraged to pursue psychiatry by medical faculty (e.g., 78% in Saudi Arabia, 52% in Colombia, and 16% in Spain). Psychiatric trainees were also seen as weak academically, with large proportions of respondents—most notably in Romania (71%) and Saudi Arabia (60%)—indicating that "many people who could not obtain a residency position in other specialties eventually enter psychiatry." These weaknesses were apparently seen as enduring, as only 44% of Saudi Arabian respondents (although, happily, 70% of Spanish and 82% of Colombian respondents) felt that psychiatrists were "clear, logical thinkers."

Perceptions of the negative views of broader society—toward our field or toward our patients—are also vividly and distressingly demonstrated in study after study. The "low prestige" of psychiatry itself was least fully endorsed in Spain, with 44% of respondents, and was greatest in Romania, with a full 89% of respondents. It is important to highlight the work of Link and colleagues (⁵—⁷) who have found that stigma is most strongly ascribed by the public to illnesses that are perceived as less "biological." Stigma may be further reinforced by the fact that the practice of psychiatry is not seen as emphasizing "physiological" factors or as being "scientific" enough by a significant proportion of respondents in Spain (22% and 12%, respectively), Colombia (33% and 31%, respectively), and Saudi Arabia (74% and 41%, respectively). In the Saudi Arabian study, the authors found that students not yet trained in psychiatry commonly (52%) endorsed clinical psychologists and social workers as "just as qualified as psychiatrists to diagnose and treat emotionally disturbed persons." Finally, the Saudi Arabian study indicates that psychiatric practitioners are seen as exploiting the role they possess, for example, with 70% of students indicating that psychiatrists "frequently abuse their legal power" in involuntary hospitalizations.

Comfort in interacting with people with mental illness was investigated in two of the studies (², ³). A large majority, 91%, of the student-respondents in Saudi Arabia, 16% of the psychiatric resident-respondents in Romania, and 52% of the other-specialty-respondents in Romania expressed discomfort with psychiatric patients. The attitudes of medical students expressed in the Nigerian study (⁴) are interesting, with "social acceptance of mentally ill people" being greatest in, for example, a social acquaintance (63%) or a gardener (46%) and least in, for example, a baby sitter (11%) or spouse (26%). This level of discomfort in dealing with the many millions of people with neuropsychiatric disease is a serious concern.

Far more encouraging are the findings related to the progress made in psychiatry, the value of clinical psychiatry, and the positive role models who populate the field of psychiatry. These results are highlighted in Table 2. The rapid expansion of the field of psychiatry was endorsed most strongly by students in Colombia (83%) and Spain (73%), and the respect with which psychiatrists are treated by colleagues was endorsed most enthusiastically by students in Saudi Arabia (91%). Respondents in several countries indicated that they found psychiatric consultation to medical or surgical patients helpful (e.g., 91% of respondents in Colombia) and, to a lesser extent, that patients benefit from psychiatric intervention (e.g., 48% of respondents in Saudi Arabia). The positive role models in our field, whether psychiatric residents or attending physicians, were enthusiastically embraced by a large majority of survey participants in Spain (92%), Saudi Arabia (85%), and Colombia (78%).

Other results that inspire at least some hope relate to the changes in perspectives expressed by medical students before and after completing some clinical training in psychiatry. For instance, in the Saudi Arabian study (³), medical students more fully endorsed the helpfulness of psychiatric consultation (from 41% to 74%, p≤0.01) and the "rapidly expanding frontier" of psychiatry (44% to 89%, p≤0.001). The students also felt that psychiatrists were "too frequently apologetic" about their field, and this perspective grew from 56% of respondents to 78% of respondents (p≤0.01) over the 4-week rotation. This study very importantly revealed a clear difference in attitudes toward the abuse of power by psychiatrists, with a decrement from 70% to 41% (p≤0.001) after the rotation of those who viewed psychiatrists as abusing power. In the Nigerian study (⁴), once medical students had some formal training in psychiatry, they more commonly rejected supernatural causes of neuropsychiatric disease, such as charms (57% to 23%, p=0.004), evil spirits (66% to 40%, p=0.045), and witchcraft (49% to 26%, p=0.021). My optimism surrounding the posttraining results are measured, though, and the reasons may be self-evident. After their training exposure, more than half of the Saudi Arabian respondents (52%) still saw psychiatry as "unscientific and imprecise," 41% still saw psychiatrists as abusing power, and 11% still rejected the view of psychiatry as progressing rapidly. Moreover, 23%—40% of Nigerian medical students still endorsed different supernatural causes of disease, while 9% still saw breast milk as a source after their clinical rotation.

As difficult as some of these findings are to read, and despite the concern that these are small and preliminary projects, the fact that we can learn about these perspectives from multiple countries across the world is a true gift to the literature. Three of the four papers I have cited, further, share a portion of their methodology. Based on the excellent initial work of Balon et al. (⁸), the authors here have implemented a survey with different groups in different countries, and this effort for the first time allows us to begin to make real and important comparisons. For instance, in this set of studies, we get the sense that psychiatric educators in Spain are very constructive and effective in their efforts to communicate the strengths of the field of psychiatry. We also get the sense that variability exists in attitudes, obstacles, and strengths in each of the five countries involved. This common endeavor permits us to see patterns beyond a local community to bring greater meaning to a field that is poorly developed and terribly underfunded. The studies must be interpreted with care, but taken together they represent a significant step forward in the transnational education literature.

The researchers were able to adapt the common methodology to answer questions of special importance to their settings too. The Saudi Arabian study looked at the measurable effect of a 4-week rotation on critically important perspectives. The Romanian study looked at the differing views of the psychiatric residents and residents from other specialties. The Spanish-Colombian study examined the similarities and differences of students in two countries with important cultural connections that exist, truly, across the world from each other. This point is worthy of emphasis: the use of a shared methodological tool, namely, a survey instrument published previously in the literature, does not preclude further creativity and hypothesis-generation and testing.

Mental illness affects people of both genders, all ages, and all nations and at this time represents the second-largest source of disease burden in the world (⁹). Psychiatric educators are charged with the responsibility of preparing physicians, whether specialists in the treatment of mental illness or not, to be capable of responding to the needs of people with neuropsychiatric disease and associated conditions. This is a global imperative. The studies published in this collection present stark challenges: How do we prevent our early career colleagues from being discouraged, disheartened, and dispirited by the harsh prejudicial views that they encounter? How do we dismantle stigma and keep it from distorting and damaging our field as well as our patients’ lives? How do we communicate effectively and with excitement the extraordinary advances of our field and the rational optimism that it correctly inspires? How do we support the positive role models and capable clinical consultants who are taught by physicians-in-training throughout the world? How do we ensure that whatever gains are made are sustained over time, given that the attitudes of the public and diminished economic and career rewards associated with psychiatry may erode the confidence and positive motivations of our professional colleagues?

Each of these difficult questions represents a tremendous challenge for academic psychiatrists. This said, the opportunities for learning from one another and the imperative for bringing about meaningful change are very brightly illuminated by this collection of papers. Indeed, the issues presented by these transnational manuscripts seem, to me, very distant from many of the concerns to which we give tremendous time and attention in North America, such as filling in long documents for elaborated bureaucracies or relentless and thwarted political arguments. It is my hope that these viewpoints from five countries on four continents will give some true perspective—and, importantly, a sense of proportion—to the kinds of challenges that we face in becoming one transnational community of academic psychiatrists committed to the care of people living with severe, stigmatized diseases with immense disability and mortality throughout this world.

Disclosures of Academic Psychiatry editors are published in each January issue.