According to the Nigerian National Health Policy, the promotion of mental health, treatment, and rehabilitation of mentally ill people has to involve the services of health care professionals at the primary care level. This implies that doctors and other health care professionals at this level should be in a position to gain access to, understand, and use information in ways that promote and maintain good mental health. Apart from exposure to mental health principles as medical students, the majority of practicing doctors in Nigeria have no further training in mental health.
Medical students—tomorrow’s clinicians—can share similar stigmatizing attitudes of society toward people with mental illness (1). Medical students often view the practice of psychiatry as unscientific, imprecise, and ineffective. Based on these prejudiced beliefs, as primary care physicians they tend to focus on physical symptoms and omit or minimize the focus on mental disorders. This lack of awareness results in both incompetent patient care and referral to mental health services (2). Psychiatry undergraduate education programs do not seem to meet the objectives of the discipline. This is largely responsible for creating negative attitudes toward psychiatry and psychiatric patients, especially among junior doctors (3). However, several studies have shown that students’ attitudes toward psychiatrists, psychiatric treatment, psychiatric patients, and psychiatry in general change significantly in a positive direction after their psychiatric training (4, 5). Students who were both knowledgeable and who had contact with mentally ill patients were less likely to endorse negative or stigmatizing attitudes toward them (6, 7). Despite the abovementioned claims, people tend to have strong beliefs about the mentally ill, and many of these concepts are based on prevailing local systems of belief.
This study examined whether a 4-week psychiatric rotation had any impact on medical students’ beliefs and attitudes toward mental illness.
This study used a prospective, cross-sectional design. The sample consisted of 35 final-year medical students receiving psychiatric training during 2007 at the Bayero University Department of Psychiatry in Kano, Nigeria. During the 4-week rotation the students attended 6 hours of theoretical lectures per week and ward rounds and clinic consultations twice a week. In addition, there were tutorial sessions on case management. Three consultant psychiatrists, two senior registrars in psychiatry, and nine psychiatric residents were involved in this training.
A 31-item pretested and self-administered questionnaire was adapted for this study from questionnaires used previously (8–10) and is available from the author. Ten psychiatric residents and three consultant psychiatrists reviewed the questionnaire, and necessary revisions were made according to their suggestions. Pearson’s r correlation analysis on questionnaire data collected on two occasions (3 weeks between the first and second collections) from 15 fifth-year medical students gave a positive correlation of 0.91. Responses were on a 3-point scale (1=agreed, 2=neutral, 3=disagreed). The individual variable responses were not scored; hence, comparison before and after clerkship was by proportions.
The first set of questionnaires, which was tagged A, was administered to students on their first day of the clerkship while in the lecture room but prior to their first lecture in psychiatry. The second set of questionnaires, tagged B, was administered just before the end-of-rotation test. The students completed the questionnaire in the presence of the attending lecturer after being advised not to exchange ideas to avoid bias.
Consent to administer the questionnaire was sought from and granted by Aminu Kano Teaching Hospital’s ethical committee and from the Dean faculty of medicine and the individual students. The responding students had assurance on the anonymity of their responses.
Data were analyzed with SPSS version 10 (1983) and presented with simple frequency distribution tables and percentages. Ordinal data were summarized with median and range values, and mean scores and standard deviations were used for numerical values. The computation of inferential tests of significance for ordinal values was with Wilcoxon signed-ranks test and Student’s t test for categorical values. Blom’s proportion estimation formula showed enough evidence that the data probably came from a normally distributed population of students.
Thirty-five students (17 men and 18 women, median age 25 years old, range=21–36 years) completed the questionnaire pre- and postclerkship.
At the start of the clerkship, four students (11.4%) could list six or more types of mental illnesses, seven students (20.0%) could list between five and six types, 22 students (62.8%) could list between one and four, and two students (5.8%) could not list any. At the end of the clerkship, 16 students (45.7%) listed more than six diagnostic entities, 14 students (40.0%) mentioned between three and six, four students (11.4%) named one or two, and one student (2.9%) was unable to list any. There was a significant difference in the mean number of diagnostic entities mentioned by students before and after the clerkship (2.00±1.11 before and 2.94±1.178 after, t=–3.95, p=0.000). Table 1 summarizes students’ pre- and postclerkship responses on the causes of mental illness.
At the start of the clerkship, 29 students (82.8%) believed that psychiatric patients were of lesser intelligence than others, and 28 students (80.0%) held the same opinion at the end of the clerkship. There were no significant differences in the pre- and postclerkship rotation beliefs that psychiatric patients were of lesser intelligence than others (p>0.05). Table 2 summarizes students’ pre and post responses on social acceptance of treated psychiatric patients.
Eighteen prerotation students (51.5%) and 25 postrotation students (71.4%) did not agree that treated psychiatric patients are dangerous to themselves (p>0.05). Fourteen prerotation students (40.0%) and 28 postrotation students (80.0%) believed that treated psychiatric patients were not dangerous to others in their surroundings (p<0.05). Before the rotation, 25 respondents (71.4%) believed that a treated psychiatric patient was unpredictable. After the rotation, 18 of the same respondents (42.9%) held this opinion (p<0.05), although 13 (37.1%) were neutral on this issue after the clerkship.
Prior to the clerkship, 20 students (57.2%) did not believe that treated psychiatric patients should serve in the army, and the same proportion did not believe that treated psychiatric patients should be medical doctors. Twenty-two students (62.8%) would not want treated psychiatric patients to serve in the police; the same proportion would also not want a treated psychiatric person as the head of state of the nation. Eleven prerotation students (31.5%) and nine postrotation students (25.7%) students did not believe that treated psychiatric patients should be appointed as a minister of education (p>0.05), and 15 prerotation students (42.9%) and 25 postrotation students (71.4%) supported having treated psychiatric patients in teaching jobs (p<0.05). After the clerkship, 18 students (51.4%) agreed that treated psychiatric patients could serve in the army and 16 students (45.7%) agreed that treated psychiatric patients could work as doctors (p<0.05). Fifteen students (42.9%) after the clerkship agreed to have treated psychiatric patients serve in the police (p<0.05), but 17 students (48.6%) did not agree to the same persons being elected as the country’s head of state (p>0.05).
This study shows that the students very likely had limited knowledge and understanding of psychiatry and psychiatric disorders before the rotation, as implied by the higher listing of diagnostic entities of mental illnesses after the clerkship.
A high proportion of the medical students believed in supernatural factors (e.g., evil spirits) as causes of mental illness, even after the clerkship. This is probably because of the influence of nonindigenous religious doctrines about demonic forces, the manifestation of God’s wrath, and witchcraft on a society with prior, deeply rooted supernatural interpretations to health matters.
In the eyes of the Nigerian public, psychiatric patients are stereotypically seen as dirty, tattered-looking, smelly, homeless, and as unpredictable, aimless wanderers who lack good reasoning (i.e., lack sanity) (7). The medical students probably imbibed stereotypes of psychiatric patients from the public, which likely explains the insignificant effect of the clerkship on their belief about psychiatric patients’ intelligence.
A significant number of students, despite holding favorable opinions about treated psychiatric patients not being a danger to self or others, believed that these persons were unpredictable. The negative attribution of fear toward treated psychiatric patients probably is the reason for the students’ distancing attitude toward them in close social contacts and rejection of having them in sensitive political offices, such as the head of a nation.
The population of study came from only one school of medicine and was very small; thus, these findings cannot be generalized.
In conclusion, there were significant changes in the students’ knowledge and beliefs about mental illness after their clinical rotation in psychiatry. Unfortunately, a high proportion believed that psychiatric patients could not be as intelligent as others and that supernatural factors could cause mental illness. The clerkship did not significantly affect their held beliefs about the unpredictability of psychiatric patients.
Mental health educators should attempt to positively influence societies’ prejudiced understanding of mental health through effective public education programs. In addition, medical students’ preclinical curriculum should include structured introductory lectures and tutorials on mental health. Final-year medical students should be encouraged to write dissertations on mental health. Doctors in practice are encouraged to attend continual medical education learning programs on mental health. The above-recommended mental health education programs, creating avenues for positive interactions between treated and stable psychiatric patients and participants, will likely bring a better understanding and appreciation of mental illness.
At the time of submission, Dr. Aghukwa reported no competing interests.