“You can’t go into psychiatry. You're AOA!” — recent comment made by an attending to a medical student
Neuropsychiatric disorders are recognized by the World Health Organization as the most important cause of disability, accounting for approximately one-third of years lost due to disability (YLD) among individuals age 15-and-over, across gender and income, around the world (1). Unipolar depressive disorders alone are the third-largest contributor to global burden of disease, and the first in middle- and high-income countries, ranking above ischemic heart disease, HIV/AIDS, and cerebrovascular disease. In the United States, it is estimated that 25% of adults have a mental illness, and nearly half will develop at least one mental illness during their lifetime (2–4). However, in 2005, of the approximately 11% of the population that met criteria for a high probability of serious mental illness, fewer than one-half (45%) reported receiving any mental health treatment in the previous year (5). The number of American mental health professionals available is already inadequate to provide for this need: there are only 13.7 psychiatrists per 100,000 population (6)—whereas the burden of psychiatric disease is projected to continue to grow (1). In the context of these findings, it is incumbent upon the medical field to effectively prepare its next generation to address psychiatric disorders. This effort to prepare the future physician workforce includes training specialists to treat mental illness, as well as educating providers in other medical specialties to be versed in general psychiatric issues, since most physicians, regardless of discipline, will treat many patients with coexisting mental illness.
The field of psychiatric education is inexorably influenced, however, by the shadow of societal stigma in which it stands. Many studies have documented the negative stereotypes and prejudicial beliefs that the general public holds toward individuals with mental illness, toward psychiatry and psychiatric treatments, and toward psychiatrists and other mental health professionals (7, 8). Although holding a neurobiological conception of psychiatric disorders has been correlated with an increased likelihood of support for psychiatric treatment, it has not been consistently shown to decrease stigma or community rejection (9). Indeed, stigma surrounding psychiatry spills over into the medical school, as well. Medical students have been found to share many of the negative stereotypes about mentally ill people that are present in the general population (10).
Psychiatry as a discipline, as compared with other specialties, tends to be viewed very negatively by entering medical students, in a manner suggesting that, to many, the field is not considered part of mainstream medical practice (11). Harsh attributions toward trainees in or approaching psychiatry have been observed both in the United States and internationally. Clerkship students note that psychiatry has low prestige among the general public and also does not have high status within medicine (12–15). These clerks describe hearing disparaging comments made about psychiatry by physicians in other fields, including residents and faculty with whom they work (16). A significant number report that family and friends discourage them from considering psychiatry as a career and that students who express interest in psychiatry risk being viewed as “odd, peculiar, or neurotic.” In some countries, psychiatric trainees are also seen as weak academically, with a large number of medical-student respondents indicating that “many people who could not obtain a residency position in other specialties eventually enter psychiatry” (12–15). Perhaps most tragic is the observation that medical students and residents in need of psychiatric care believe that if they seek appropriate treatment, and it becomes known, they will receive worse grades for equal academic performance than their peers (17–19). Furthermore, medical students fear that receiving psychiatric care will jeopardize their future career opportunities because of prejudicial attitudes that will be expressed in their “dean’s letter”—the key recommendation that shapes their future residency position. These fears heighten, rather than diminish, as students progress through their clinical training (19–21).
Psychiatry’s perceived low status among medical students, their friends and family, as well as within the medical community as a whole, is particularly worrisome in the context of the disease burden and workforce needs. There is a remarkable contrast between the extent to which students view psychiatry as an intellectually-stimulating field with an attractive lifestyle and the low rate at which it is chosen as a specialty. Across the board, students note that the status of psychiatry in society has a negative effect on their interest in entering the field (22). Of even greater concern, stigmatization of individuals with mental illness appears to adversely affect students’ willingness to work with psychiatric patients, by pre-labeling them as frustrating or hopeless (16). In 2011, only 4.1% of graduating U.S. medical students applied for residency positions in psychiatry: 698 applicants for 1,097 available PGY-1 positions in the category of psychiatry (23). Even considering U.S. and international medical graduates together, 16 of 183 general-psychiatry residency training programs nationwide did not fill all of their positions in the NRMP match (23). Given estimates suggesting that about 1,000 general psychiatrists would need to graduate from psychiatry residency each year in order to maintain even the current workforce numbers (24), this low rate of training in psychiatry leaves the field far from being able to meet growing needs.
The fact that disability due to mental illness continues to rise while treatment needs remain unmet and while stigma stifles early-career physicians’ commitment to psychiatry points to a vital need for the medical community to actively address the issue of stigma in psychiatry. Addressing stigma must be undertaken, thoughtfully, rigorously, and explicitly, on every level—from academic leaders in the health profession at large, to psychiatric educators, to undergraduate and graduate trainees. Stigma-reduction interventions in undergraduate and graduate medical education, moreover, should be theoretically grounded and empirically tested.
Models for addressing stigma have been developed in sociology and social psychology, largely in the context of stigma toward ethnic and other minority groups (25, 26). Such models, which have been applied in the literature to stigma experienced by individuals with severe mental illness (26), suggest that there are three primary types of interventions for stigma reduction: 1) protest, or highlighting stigma in its various forms and reprimanding offenders; 2) education, or providing accurate, factual information; and 3) contact, or facilitating interpersonal interaction with members of a stigmatized group. Although protest strategies have been demonstrated anecdotally to suppress prejudices or decrease harmful behaviors, there is also evidence to suggest that protest is ineffective, or, at worst, can increase prejudice (see Corrigan and Shapiro (27) for a review of this topic). Education has been shown to lead to some short-term improvement in attitudes, but its effect on stigma, overall, has been inconsistent. Interpersonal-contact interventions, on the other hand, have demonstrated significant likelihood of decreasing prejudice in certain contexts: when there is equity of status, one-on-one contact, contact that includes a common goal, contact that involves something rewarding, and interactions with a person who moderately disconfirms prevailing stereotypes (27). Stigma has been noted to be lower among people who have experienced personal contact with mental illness, where contact is defined as a history of psychiatric hospitalization oneself, or among family members or friends (28). A review of stigma-reduction initiatives among young people, including medical students, bears these findings out in this population as well: on the whole, “contact conditions,” in which individuals have the opportunity to meet with people with mental health problems, lead to a greater decrease in stigma than “educational conditions” in which they receive presentations by professionals (29). Given these findings, stigma reduction in psychiatric education may mean providing explicit information about dealing with individuals with mental illness and about the field of psychiatry as a whole. Perhaps more importantly, though, it should involve providing opportunity for interpersonal contact and the development of empathy.
Interpersonal, empathy-based contact approaches in psychiatric education may occur in a number of ways. At the early-trainee level, promising interventions have been described, including arranging for early medical students to meet and talk with a young person with serious mental illness, showing a film about an individual with schizophrenia, and having students interact with the families of people with mental illness (30, 31). Also, a study has suggested that giving medical students the opportunity to see psychiatric patients in community, primary-care settings with general practitioners served to counter stigmatizing views toward patients and toward the field (32). At present, although a number of anti-stigma initiatives in the medical community have been documented, there remains a paucity of data regarding measures of lasting behavioral change, as well as regarding the generalizability of interventions. For example, one study of medical students in Hong Kong suggested that while an educational anti-stigma intervention led to significantly improved attitudes, attributes of responsibility and readiness to provide medical care for psychiatric patients were most resistant to change (33). More opportunities should be sought for medical students to have contact with people with mental illness, including those who are doing well, in non-clinical settings where equity of status is maintained. These encounters are especially vital given the pressures of the medical education process, in which medical students are frequently exposed only to individuals at their sickest, and where they may find that, for purposes of learning diagnosis and treatment planning, it is often simplest to “reduce an individual to a disease.”
The principle of contact interventions as a tool for destigmatization can also be applied more broadly to the field of psychiatry, as a whole. Throughout the medical community, the importance of healthy collaboration between psychiatrists and other medical specialists and health workers should be underscored. Involvement of psychiatric educators in a broad range of medical student experiences and encounters, above and beyond the psychiatry clerkship, is key.
For psychiatric residents, who have already chosen to enter the field, the issue of stigma should be explicitly addressed as a professional reality and a potential stressor (10). The dual position of psychiatrists as “stigmatized” and “stigmatizers” should be thoughtfully considered. With regard to being “stigmatized,” residents should be exposed to an understanding of where stigma comes from and how to think about dealing with preconceived notions of the field. They may benefit from considering behaviors that may serve to decrease the stigmatization of psychiatry, including collaboration with others in medicine, respectful relationships with patients and families, clinical practice that is in line with advances in psychiatric research, and strict observance of ethical principles (8). With regard to being “stigmatizers,” residents should have the opportunity to think about their own views of individuals with mental illness, and how experiences they have during their training might increase or decrease stigma toward patients. Inherent in many clinical services, especially the inpatient services where many residents spend the early part of their careers, is a pattern of intensive, continuous contact with people who are unwell, along with the selective discontinuation of interaction with people when they are well: this in itself may lead to a pessimistic view of the prognosis for people with mental illness (34). As challenging as it is for residents in all medical fields to resist the decline in empathy that tends to occur over the course of medical training (35), in psychiatry, it is doubly important that residents be challenged to view their patients as “whole people,” given the negative and prejudicial attitudes that many of their patients face. Specific learning may be directed at how to communicate with patients and their families so as not to increase stigma for them. Finally, attention should be given in residency to the issue of how psychiatrists advocate for their patients and educate the public, setting the stage for a generation of mental health professionals equipped to effectively combat stigma over the course of their careers.
A robust mental health profession is vital to improving health outcomes in the 21st century, and deconstructing stigma within psychiatric education is central to strengthening the future of the mental health profession. Drawing upon stigma-reduction interventions that have been demonstrated to have a positive impact on trainees, as well as taking into account theoretical models of social change born in other fields, further empirical study of this topic is essential. In order to be equipped to meet the upcoming needs, stigma-reduction initiatives must be scaled to occur across the medical community and must be designed with a lasting impact in mind, to foster physicians across the professional lifespan to effectively treat mental illness.