Medical students without psychiatric experience often display negative attitudes toward the subject of psychiatry (1). Nonetheless, medical students’ attitudes toward psychiatry and mentally ill patients are important for their behavior as medical doctors (2). The reduction of this crucial bias in medical students is a fundamental challenge in undergraduate medical education.

Movies have been used for teaching psychiatry in order to increase students’ understanding of mental disorders and to decrease prejudices (3, 4). In postgraduate psychiatry education, the presentation of contemporary movies followed by group discussions has been used since the late 1970s (5), and specific movies have also been applied in clinical case conferences (6). Commercial movies have also been used successfully in order to assist educators training residents in topics that are relevant to psychiatry (7).

As the use of cinema in postgraduate psychiatry training has gained increasing levels of acceptance, a study module for third-year medical students has been established at King’s College, London, that utilizes movies in the study of mental illness, psychiatry, and psychiatrists (8). Another special study module, “Psychiatry and Film,” was developed at St. George’s, University of London, with the intention of encouraging medical students to consider psychiatry as a potential career specialty and to reduce negative attitudes toward mental illness (9). A comprehensive list of good-to-excellent portrayals of psychiatric conditions has been published, along with the name of the actor portraying the character of interest and the country and year of release for each film (10).

Movies have been used successfully for various learning objectives in undergraduate medical education in various formats and settings (11–13). Their particular value for improving teaching in the psychosocial disciplines was discussed some years ago, and the recommendation was made to use multi-media modules in settings involving blended learning (14). In spite of the finding that fictional movies can be useful for training observers in recognizing personality pathologies and personality traits (15), no specific teaching format has yet been established and evaluated as part of a broader scheme. It has been shown that a well-designed teaching format helped students who had neutral attitudes toward psychiatry at the beginning of a psychiatry clerkship to develop more favorable attitudes toward psychiatry by the end of the rotation (16). Furthermore, empathy has been named as an essential learning objective by the American Association of Medical Colleges (17). Empathy involves understanding the patient’s situation, perspective, and feelings, communicating that understanding, and acting on it in a therapeutic way (18).

We developed a psychiatric “cinemeducation seminar” for undergraduate medical students by combining a movie with a short lecture and a patient interview, each based on the same disease, as a new teaching format. Participating students were asked whether they valued this teaching format as an introduction to psychiatric illness in general. The suitability of various movies for studying specific psychiatric conditions was established from the students’ perspective with regard to reaching the specific learning objectives: “gaining an impression of a specific psychiatric disease” and “being able to put oneself in the position of a person suffering from the psychiatric disease in question.”

Between January 2005 and December 2008, three to four different cinemeducation seminars took place per trimester (i.e., a maximum of 12 movie seminars per calendar year) and were evaluated at the Medical Faculty of Hamburg University in Germany. The seminars were held during the Psychosocial Medicine module. This module is one of six mandatory modules chosen by the students between Years 3 and 5 of their 6-year undergraduate medical curriculum. Approximately 130 students participate in each module. Students from the Psychosocial Medicine module were able to attend up to four cinemeducation seminars, which took place from 6 P.M. to 10 P.M. Participation was voluntary, and each seminar comprised three elements:

• A short general introduction to the movie, followed by the presentation of one of the movies from Table 1;

• A discussion about the movie, plus a short lecture about the specific psychiatric disease seen in the movie, focusing on a diagnosis based on the ICD-10/ DSM-IV and therapy; and

• A patient interview with student participation, in which a patient suffering from the specific disease shown in the movie discusses his/her personal experience of this disease and its therapy, including the effects of the disease on his/her personal life.

After each seminar, a paper-and-pencil evaluation was performed. In addition to the participants’ sociodemographic data, questions covering the general satisfaction of the students with this new teaching format, the selection of the movies, the achievement of the learning objectives, the didactic quality of the teachers, and organizational matters were included. The participant’s agreement or disagreement with each statement was to be indicated on a 6-point Likert scale (1: “I strongly agree;” 2: “I agree;” 3: “I moderately agree;” 4: “I moderately disagree;” 5: “I disagree;” 6: “I strongly disagree.”). The resulting scores were treated as continuous interval-scaled variables. All data were analyzed with SPSS 17.0. In addition to calculating the descriptive parameters, frequency, central tendency (arithmetic mean [M]), and dispersion (standard deviation [SD]), several comparisons of the means were made in order to identify differences between individual movies or movies according to disease-groups; that is, two-sample t-tests and one-way analysis of variance with multiple-comparison correction according to Bonferroni, which includes an adjustment of the family-wise error rate (19), were performed. The tests were two-tailed, with a critical p value of 0.05.

Evaluation questionnaires from 12 trimesters (between January 2005 and December 2008), covering 39 seminars were included in this study. A total of 1,032 students (approximately 33% of all medical students in the average clinical-year group) returned the questionnaires. Of these respondents, 27.0% (N=279) were men, and 71.8% (N=741) were women; 1.2% (N=12) did not answer the question regarding gender. The mean age of the respondents was 25.2 (SD: 4.7) years. The majority of participants (89.5%) were full-time students at the Medical Faculty of Hamburg, Germany, and 73.5% of the students were enrolled in the thematic block Psychosocial Medicine, which includes the subject Psychiatry; 26.5% were studying a different thematic block, such as Diagnostic Medicine or Operative Medicine. About 10% of participants were studying in other faculties (e.g., psychology). All of the calculated means were within the positive range (1–3) of the 6-point Likert scale (Table 2). The students particularly valued the combination of movie and seminar (1.4 [SD: 0.7]), and felt that the cinemeducation seminar was useful for giving them access to the subject of psychiatry (1.5 [SD: 0.7]). They found the patient interview to be a helpful addition for understanding the underlying psychiatric disease (1.6 [SD: 0.9]). All learning objectives were ranked within a satisfactory range (1.8–3.0), with “I gained an impression of the treatment options for the specific disease” being given the lowest rating (3.0 [SD: 1.3]). The organization of the seminar as a whole was rated positively (1.5 [SD: 0.8]).

All movies were compared with regard to their usefulness in reaching the learning objectives “I found the movie appropriate to gain an impression of XXX disease” (XXX: the respective psychiatric illness shown during the cinemeducation seminar) and “The movie helped me to put myself in the position of a person suffering from XXX disease,” independently of the disease category being covered (Table 3). The highest-ranking films for being “appropriate for gaining an impression of a certain psychiatric disease” were Dark Days, a film about depression (1.4 [SD: 0.9]) and A Beautiful Mind (1.5 [SD: 0.7]) and The White Sound (1.6±0.8), which are both movies about schizophrenia. As far as being “helpful with regard to putting myself in the position of a person suffering from a certain psychiatric disease,” A Beautiful Mind (1.6 [SD: 0.7]), The White Sound (1.9 [SD: 0.9]), Iris (2.0 [SD: 1.0]), and Alone (2.0 [SD: 0.9]) were assigned the highest ranks.

Movies have been used in various educational settings for a wide range of learning objectives in undergraduate and postgraduate medical education (15, 20–24). However, most studies regarding a psychiatric movie-seminar format included very few participants (8, 15, 22), and nearly all of the seminars combined the presentation of a movie with a discussion and an evaluation only (5, 22). A new format for a cinemeducation seminar, consisting of the presentation of a movie, a short lecture, and a patient interview, including a discussion, was implemented in our study. All three parts covered the same disease or disorder. The students rated this format very highly. They felt that the cinemeducation seminar gave them access to the subject of psychiatry and that the patient interview was useful for understanding the underlying psychiatric disease presented in the movie. The learning-objective “I gained an impression of the treatment options for a certain psychiatric disease” received the lowest rating, as “treatment” was not a specific learning objective of the movie seminar, but rather part of the obligatory lectures. Nevertheless, Walter et al. (21) showed that treatment options can also be covered in movie seminars when this learning objective is intended. Even though the cinemeducation seminar was an optional course and was held at unusual hours (6 P.M. to 10 P.M.), it was well attended (by up to 59 participants per seminar), thereby reflecting the students’ educational interests. Because educational programs can influence the attitudes of medical students toward psychiatry (25), and as the students seemed to feel that the learning objectives were reached very well with this new type of seminar, it might find its place within the regular undergraduate medical curriculum.

Dark Days, a film about depression, and two movies about schizophrenia, A Beautiful Mind and The White Sound, were regarded as the most useful movies for the learning objectives “I found the movie appropriate for gaining an impression of a certain psychiatric disease,” and “The movie helped me to put myself in the position of a person suffering from a certain psychiatric disease.” A Beautiful Mind has been described as being very suitable for teaching about schizophrenia, as it shows a range of symptoms and complications and gives the viewers a sense of hope for recovery (26). The White Sound had positive effects on a subgroup of non-medical people who had previously been in contact with people suffering from schizophrenia by reducing prejudices and stereotypical attitudes (27). Within the group of movies covering “neurotic,” stress-related, and somatoform disorders, the movie Elling seems to be the most valuable for reaching the learning objectives. This evaluation might be helpful in improving the selection of movies for future seminars. The suitability of using commercially-available movies to teach students about borderline personality disorders has previously been demonstrated (28) and received high marks from the students in our seminars. To introduce a seminar with a similar format into the mandatory part of a curriculum, a careful selection of suitable conditions and the relevant movies (with regard to the specific learning objectives) needs to be made. A comprehensive list of good-to-excellent portrayals of psychiatric conditions has recently been published (10). It covers the major categories of mental illness and can help teachers to make choices depending on their requirements for meeting the learning objectives. An analysis of more than 450 movies regarding the image of psychiatrists and the influence of psychoanalytical ideas in American movies could also be recommended to interested readers who would like to gain a deeper understanding of psychiatry in movies (29).

Our study had several limitations. The movie seminar was an optional seminar, which could lead to biased results if only students with a special interest in psychiatry participated. This could also increase positive evaluation results. Students’ subjective experiences and opinions only were used for the analysis of whether the learning objectives had been reached. Although this seminar gave the students the impression that they had reached the learning objective of recognizing the symptoms of a certain psychiatric disease, this was not assessed by introducing control groups because of the legal regulations governing voluntary courses. Furthermore, the students were not asked at the beginning of the study how they felt about the respective learning objectives, meaning that no pre–post comparison was possible regarding these items or a shift in attitude, which was an additional limitation of our study. Some students may have had other types of professional or personal experience with people with mental disorders in a private context, which could have been a confounder in this study.

In summary, with regard to the new teaching format of the cinemeducation seminar, including the presentation of a commercially-available movie, a short lecture, and a patient-interview with discussion, the students felt that they had been able to access the subject of psychiatry and improve their understanding of the psychiatric disease in question. Movies about dementia, schizophrenia, and borderline diseases were particularly useful, from the students’ perspective, for gaining an impression of a certain psychiatric disease and for enabling students to put themselves in the position of a person suffering from that disease. The results suggest possible benefits of the incorporation of this teaching format into the undergraduate psychiatric curriculum. Future studies could focus on the degree to which the seminar enhances students’ psychiatric knowledge-base and attitudes toward individuals experiencing psychiatric disorders when compared with traditional teaching approaches.