Key Words: mental illness; medical students; attitudes; stigmatization

The one-year prevalence of any psychiatric disorder was reported as 28.1% in the USA. The one-year prevalence for some of the mental illnesses are as follows; unipolar major depression 5.0%, panic disorder 1.3%, schizophrenic/schizophreniform disorders 1.1%, cognitive impairment 2.7%, any alcohol disorder 7.4%, any substance use disorder 9.5%. The lifetime prevalence rates of these diseases are almost twice the one-year prevalence (1). In recent years, there has been a revolutionary change in the systems of care and treatment devised for mentally ill patients that has involved a movement away from institutional care, towards greater involvement in the community (2). An increased need for the rehabilitation of mentally ill subjects was prompted by the worldwide movement of deinstitutionalisation. Individualized rehabilitation must be in mutual interaction with the social and occupational environment.

The objective of rehabilitation is to enable the patients after their recovery, to acquire their former social and occupational status and to help the disabled and handicapped to achieve the maximum in health, work competence, occupational and social integration and quality of life (3). However, numerous studies show the persistence of negative attitudes of the public towards the mentally ill. In spite of the insertion of psychiatry in the community, stereotypes and stigmatization of psychiatric patients did not change accordingly (4,5). An important gap exists between the beliefs of the population and present psychiatric knowledge (4). Studies about population attitudes towards mentally ill show that people are afraid of mentally ill patients, would not employ them, would not marry them, would not establish any relationships with them, and mentally ill patients are considered as violent (6).
Stigmatization of mentally ill patients has negative effects in their rehabilitation. In this regard, the attitudes towards mentally ill patients, especially the attitudes of health professionals, which might play a major role as a model to public attitudes, could be a major factor in defining the quality of the future life of the mentally ill. The aim of this study was to determine the opinions and attitudes of first and final year medical students towards mentally ill patients, and to compare the attitudes of the two groups to see the effects of medical education and confronting the patients, and to evaluate the stigmatization of the mentally ill by future medical professionals.

The study was carried out during May 2003, in Erciyes University Medical School, Kayseri, Turkey. There are 40 medical schools in Turkey, and Erciyes University Medical Faculty is one of the oldest schools, which was founded in 1968. Kayseri is a trade center in central Anatolia, and has a population of 536,000.

A questionnaire comprising 19 questions was designed by using the structure used by former studies regarding the attitudes towards mentally ill (7,8). The questionnaire was administered to the first and final year medical students. There were 204 first year and 184 final year medical students, and there were 1,281 students in total in the medical school. The duration of medical education is six years. The first year medical students have 42 hours of psychology (behavioral sciences) lessons. The third year medical students have 15 hours of psychiatry lessons. The fifth year medical students have 18 days of psychiatry clerkship with 45 hours of lessons. The final year medical students are studying at psychiatry wards and clinics for one month.

The questionnaire was collected immediately after it was filled out. There was no information given to the students about the diseases in order not to affect the current points of view of the students. The names of the students were not written on the questionnaire in order to make the students feel comfortable in filling out the form.

There were 308 students who filled out the questionnaire. The response rate was 81% of the total group. One hundred and forty seven were first year and 161 were final year medical students. Of the first year students, 43.5% (64/147) were female and 56.5% (83/147) were male. Of the last year students 50.3% (81/161) were female and 49.7% (80/161) were male. The mean age of the study group was 22.4 ± 2.8.

The questionnaire consisted of two parts. The first part had thirteen general questions about the attitudes towards mentally ill patients (Table 1) (7). In the second part of the questionnaire, eight opinions about six mental illnesses: severe depression, panic disorder, schizophrenia, dementia, alcohol disorder, and any substance use disorder were asked (Table 2) (8).

The questionnaire was administered to five first year and five final year medical students to perform a pilot study. No change in the questionnaire was required due to the results of this study. The questionnaire was administered to both of the years at the end of the year when the lessons of the first year students were completed and the last year students were about to complete their studies at the psychiatry department. Medical students who are members of 'the scientific research group of psychiatry' delivered the questionnaire. The sample can be considered representative of the students of our medical schools, however we cannot say that the group represents all of the medical students in Turkey.

Statistical analysis was performed using SPSS statistical package (Version 11.0, SPSS Inc., Chicago, Il, USA) for Windows. Chi-square tests were used to determine the differences between the groups. The level of statistical significance was set at p < 0.05.

The last year students met and talked with psychiatric patients more than the first year students (Table 3). The difference of answers about recognizing a psychiatric patient was statistically significant (p<0.001). Observation and talking were the most common preferred choices in both of the groups for recognizing a psychiatric patient.

The final year students felt more indifferent (17.5%), less fear (5.6%), and less compassion (13.1%) when they saw a psychiatric patient (p<0.001). Most of the students of both groups tended to continue their relationships with a friend who had a psychiatric disease. There was no statistically significant difference between the choices of marrying a psychiatric patient of the two groups, where 91.6% of the first year and 88.0% of the last year medical students do not want to marry. Most of the first year (71.4%) and the final year (74.3%) medical students thought that psychiatric patients could hurt someone. In both of the groups (first year and final year students), hospitals (15.6% vs. 12.5%), care houses (19.0% vs. 5.0%), together with the other people (25.1% vs. 28.7%) and multiple choices (23.1% vs. 32.5%) were stated for places psychiatric patients should live. The final year students would give a job to a mentally ill patient, more than the first year students (p = 0.030). There was a difference as well between the students who knew a psychiatric patient and the other students, in giving a job, where the ones who knew such a patient would give them a job with a higher percentage (p = 0.009). The percentage of students who said that they did not hesitate in examining a psychiatric patient was not statistically significant.

In a question where multiple choices could be marked, the first year medical students mainly thought that psychiatry patients were strange (22.4%), unforeseeable (24.4%), strange and unforeseeable (25.8%). The final year medical students also thought that these patients were strange and unforeseeable (18.6%), and unforeseeable (31.0%). Seventeen first year students (11.5%) and 30 (18.6%) of the final year students defined psychiatric patients as 'like everyone else'. Forty-seven (31.9%) of the first year medical students stated that the causes of psychiatric diseases are due to life experiences, 43 (29.2%) due to genetic factors and life experiences, and 34 (23.1%) to both genetic factors, life experiences and organic reasons (multiple choices could be marked). The final year medical students evaluated the causes of psychiatric diseases as: 94 (58.3%) due to genetic factors, life experiences and organic reasons, 20 (12.4%) to genetic factors and life experiences, and 13 (8.0%) to genetic factors, life experiences, organic reasons and other reasons.Ten (6.8%) students from the first year and 11 (6.8%) students from the final year evaluated the causes as life experiences and organic factors.

When the diseases were separately evaluated, there were more differences between the first and last year students on evaluating mentally ill patients (Table 4). The final year students stated that patients suffering from severe depression as less 'dangerous to others', more 'unforeseeable', 'blame themselves' more, and 'can take care of themselves' less. The opinions of the two groups are almost totally different for panic disorder, where the final year students stated that they were less 'dangerous/aggressive', more 'unforeseeable', not 'hard to communicate', 'blame themselves' less, 'can take care of themselves' more, and 'harm themselves' less. The evaluation of schizophrenia patients was very different as well, where the final year students thought that they were more 'dangerous', 'harder to communicate', 'can take care of themselves' less, 'never cured' more, and 'harm themselves' more. The differences were less in the evaluation of dementia, alcohol disorder, and any substance use disorder. The final year students thought that dementia patients 'blame themselves' less, 'could take care of themselves' less, and 'not cured' more. The only difference for alcohol disorder was that the last year students thought that they 'blame themselves' more. For any substance use disorder, the final year students thought that they are more 'unforeseeable', and 'blame themselves' less.

It was an expected result to see that the final year students knew, met and talked with psychiatric patients more than the first year students, due to the medical school curriculum. The final year students felt more indifferent, less fear, and less compassion when they saw a psychiatric patient. When the diseases were separately evaluated, there were more differences between the first and last year students on evaluating mentally ill patients.

There are some limitations in this study. The first limitation of this study was not to administer the same questionnaire to the same student group after 6 years training. The second limitation was that the demographic properties of the study groups were disregarded, because the main aim was to see the changes caused by the education given throughout the medical school years. General questions on mentally ill patients were not separately asked for neurotic patients and psychotic patients in order to compare the results with the present literature data.

Although there are studies regarding the attitudes towards mentally ill patients (4-8), we could not find a study on the attitudes of medical students. Blizard has found no differences in the attitudes towards the mentally ill patients between university students and the rest of the community (9,10). However, it is possible to expect some differences with the attitudes of the community and the medical students, especially the final year students.

Vezzoli et al. have reported in a community study 52%-70% who have talked with psychiatric patients and 21%-45% who often meet with psychiatric patients (7). This is compliant with the final year students' percentage, which declare that they frequently meet and talk with psychiatric patients.

It has been reported in various studies that family therapy is better than conventional treatment and individual therapy when relapse rates are considered (10-12). In our study group, we could not get satisfactory answers about deinstitutionalisation of the psychiatric patients. This is probably due to the ideas of students that psychiatric patients are dangerous/aggressive, not cured with treatment, which is stigmatization.

Vezzoli et al. have reported that students and the unemployed would give psychiatric patients a job (86%), whilst the self-employed were less willing (57%) (7). In this study, last year students would give a job compliant with the self-employed (Table 3). This may not be attributed only to negative opinions whilst some of the patients cannot actually work properly.

Crisp et al. have reported in a community study that 62% of the respondents rated people with severe depression as hard to talk to, 19% responded that they could pull themselves together, 23% that they would not eventually recover, and 23% that they are dangerous to others, yet only 16% thought that they would not respond to treatment (8). In this study, the medical students think that it is harder to communicate with patients suffering from severe depression, probably because they have to take a detailed history of the patient. The ideas of the medical students about being not cured are less (First year: 9.8%, final year: 8.8%) when compared with the 16% in Crisp et al.'s study. It is possible to say that social intercourse and more work experience with psychiatric patients have made a change in how the final year students feel about the patients. Feeling indifferent and having less fear can be considered as a positive change in the evaluation of the patients from the point of view of doctor-patient relationship. Having less compassion for a patient can be unimportant as a medical professional, but this must not lead to disregarding and bad manners towards the patient, and loss of empathy for the patient.
Objection of marrying with a psychiatric patient cannot be considered as stigmatizing the mentally ill patients, but a normal manner for protecting themselves. Some of the psychiatric patients can be dangerous and aggressive during the course of the disease, but this does not mean that they are always dangerous and aggressive. This condition must not lead to the stigmatization of the patients.

It might be expected to see that none or nearly none of the final year students would hesitate to examine a psychiatric patient. Confronting the mentally ill patients has made the final year students think that less of the patients are strange, but more of them are unforeseeable. We might expect to see more of the final year students stating that psychiatric patients are like everyone else, but probably due to considering only the psychotic patients, there is no difference between the two groups for this item.