Attitudes towards psychiatry of undergraduate medical students at Bayero University , Nigeria

According to the World Health Organization, 10 18% of Nigerians suffer from mental or psychological disorders, both mild and more disabling (it has been estimated that about a third of patients attending general health services clinics suffer from some form of mental disorders), and psychiatric disorders are among the 10 top causes of global economic burden. There is also an increasing trend of drug and alcohol abuse among Nigerian youth.


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According to the World Health Organization, 10 -18% of Nigerians suffer from mental or psychological disorders, both mild and more disabling (it has been estimated that about a third of patients attending general health services clinics suffer from some form of mental disorders), and psychiatric disorders are among the 10 top causes of global economic burden. 1,2There is also an increasing trend of drug and alcohol abuse among Nigerian youth. 3e provision of mental health services to all citizens of Nigeria by the year 2000 and beyond, a goal highlighted in the National Mental Health Policy, 4 is far from being realised owing to scarcity of both mental health facilities and personnel.It is estimated that 400 psychiatrists are needed to have the minimum required impact on mental health coverage.Nigeria currently has 120 psychiatrists serving a population of over 140 000 000. 4 Postgraduate medical training in Nigeria is stressful, spanning 4 -6 years, and trainees require good coping skills. 5Time pressure, frequent examinations, a high workload, poor pay, and physical and emotional problems experienced by trainees are among the reasons that have been given for the stressfulness of residency. 6spite these obstacles, a rising proportion of Nigerian doctors seek postgraduate medical education due to the large number of doctors who are qualifying, increased remuneration and prestige for specialists, and an ever more competitive practice environment globally. 7However, despite an increase in the number of doctors who decide to specialise, a relatively small proportion choose to do so in psychiatry. 3inical clerkship in psychiatry for undergraduates at Bayero University medical school takes place during the students' 6th academic year, lasting for 4 weeks.During this period, the students receive 6 hours of theoretical lectures per week and do twice-weekly ward rounds and clinic consultations.
Undergraduate students' attitudes towards psychiatry potentially have important implications for their future practice, not only influencing the way they will respond to psychological problems in their patients, but also in terms of recruitment into the field

Attitudes towards psychiatry of undergraduate medical students at
Bayero University, Nigeria Department of Psychiatry, Aminu Kano Teaching Hospital, Kano, Nigeria Background.This study determined and compared responses of 5th-and 6th (final)-year medical students on their attitudes to psychiatry as a profession.Also elicited were their choices of area of future medical specialisation.
Method.A prospective and cross-sectional study using an adapted 27-item self-administered questionnaire to obtain responses from 91 5th-and 6th-year medical students at Bayero University, Kano, Nigeria.
Results.More than 60% of the students' first choices for future specialisation were surgery, obstetrics/gynaecology or internal medicine.Psychiatry was the first preference for less than 2%.More than 75% of the students' views on the overall merits and efficacy of psychiatry were positive, although they felt that psychiatry had low prestige and status as a profession.
In addition, the same proportion considered that psychiatry was scientific, making advances in the treatment of major mental disorders, and helpful in liaison practice.More than 50% stated that psychiatry would not be their choice of last resort for residency education and the same proportion felt that friends and fellow students rather than family members would discourage them from specialising in psychiatry.More than 50% would feel uncomfortable with mentally ill patients, felt that psychiatry would not be financially rewarding, and did not think that psychiatrists abuse their legal power to hospitalise patients.
Attitudes of the two groups of students to psychiatry as a profession were not significantly different (p>0.05).

Conclusion.
A clinical clerkship in psychiatry did not influence the students' choice of future specialisation.articles of psychiatry. 8,9However, having a positive attitude towards psychiatry does not guarantee selection of psychiatry as an area of professional specialisation. 10Positive experiences during students' clerkship in psychiatry and their personal contact with mental illness increase the likelihood that they will have positive attitudes towards the profession, 11 but because of other deciding factors may well not guarantee an increase in the number wishing to specialise in psychiatry. 11The competition from other medical departments for curriculum time in medical schools has reduced the duration of medical students' exposure to psychiatry clerkship, [12][13][14] and this not only negatively affects students' acquisition of knowledge in psychiatry but also undermines their understanding of its importance as a field of medicine.
Reintegrating psychiatry, neurology, and other areas of clinical neurosciences in the medical school curriculum, thereby allotting more time to psychiatry, has been the focus of considerable interest in recent years. 15,168][19] Like the Nigerian public, many of our medical students believe in the influence of supernatural forces (evil spirits) in the causation of mental illness, and that even when they have been treated, psychiatric patients are unpredictable and lacking in intelligence. 20,21The Nigerian public's stereotypes of psychiatric patients are largely derived from the vagrants wandering the streets of the country. 22,233][24] Medical students would be expected to be better informed and more accepting of mental illness, 22 but have been found to have negative attitudes similar to those of the general public. 25e present study set out to determine medical students' attitudes towards psychiatry as a profession and a choice for future specialisation.The study, which as far as the author is aware is the first in this geographical area, also investigated the effect of clerkship on students' views of psychiatry.

Methods
A prospective and comparative study was conducted among 5th- The questionnaire was tested for ease of understanding among 20 selected 4th-year clinical medical students, and necessary revisions were made.
Data were analysed with SPSS version 10, simple frequency distribution tables were used, categorical values were summarised in absolute numbers, and percentages were calculated to one decimal place.Tests of association between the final-year and 5th-year students' responses were done using the chi-square test.

Results
The study population of 119 consisted of 35 6th-year and 84 5th-year students.

Socio-demographic characteristics
Sixty-six (78.6%) of the 5th-year students and 25 (71.4%) of the 6th-years completed the questionnaire.The mean ages of the two groups were 24.6 and 24.8 years, respectively.Their sociodemographic characteristics are summarised in Table I.Three 6th-year students (12.0%) selected paediatrics, 4 (16.0%)chose family medicine as their area of future specialisation, and 1 each (4.0%) chose neurology, diagnostic radiology, anaesthesia and emergency medicine.Three (12.0%) of the 6th-year students were undecided about their preferred field of future specialisation, and none wanted to specialise in psychiatry.

Attitudes of the medical students towards psychiatry
Overall merits and efficacy of psychiatry.Nineteen (76.0%) of the 25 6th-year students and 58 (87.9%) of the 66 5th-years agreed with the statement that modern psychiatry was making advances in ways of rendering efficient care to patients with major mental disorders (χ Cross-tabulation analysis of the final-year and 5th-year students' responses with regard to the overall merit and efficacy of psychiatry did not show any significant differences (p>0.05).

Role definition and functioning of a psychiatrist.
Twenty-three (92.0%) 6th-year and 55 (83.3%) 5th-year students disagreed with the statement that psychiatry is not a genuine and valid branch of medicine; 12 (48.0%)and 48 (72.7%), respectively, were of the opinion that most psychiatrists were clear, logical thinkers; 15 (60.0%) and 39 (59.1%), respectively, disagreed with the view that clinical psychologists and social workers were as qualified as psychiatrists to diagnose and treat emotionally disturbed persons; 13 (52.0%)and 48 (72.7%), respectively, were of the opinion that psychiatrists had the most authority and influence among mental health professionals; 19 (76.0%) and 40 (60.6%),respectively, did not agree that psychiatrists were frequently apologetic; 20 (80%) and 52 (78.8%), respectively, did not think that psychiatry was too 'biologically minded'; and 14 (56.0%) and 34 (51.5%),respectively, did not agree that psychiatry was too analytical, theoretical and psychodynamic.
As seen in Table II, there were no significant differences between the 6th-and 5th-year students' responses with regard to the role and functioning of a psychiatrist (p>0.05).
Possible abuse and social criticism.Sixteen (64.0%) and 39 (59.1%) of 6th-and 5th-year students, respectively, did not agree that psychiatrists frequently abuse their legal power to hospitalise patients against their will.Thirteen (52.0%) and 44 (66.7%), respectively, did not perceive that psychiatrists make as much money as most other doctors.There were no statistically significant differences between the 6th-and 5th-year students' responses on the above (χ 2 (1, N= 91) =0.341, p>0.05 for abuse of legal power and χ 2 (1, N=91) =0.231, p>0.05 for social criticism).
Career and personal reward.Sixteen (64.0%) 6th-year Cross-tabulation analyses of the 6th-year and 5th-year students' opinions about psychiatry as a career showed no statistically significant differences (p>0.05)(Table III).

Discussion and conclusion
The findings of this study indicate that medical students' choice of psychiatry as a field of future medical specialisation probably depends on factors that may not be favourably influenced during clerkship in psychiatry.Despite the fact that the majority would not opt to specialise in psychiatry, the students' attitudes with regard to most of the variables tested were positive.This result is consistent with some earlier studies that found positive changes in students' attitudes towards psychiatry after clerkship, without similar changes in their choice of future area of specialisation. 10,13,25 H3][14] Our students' 4-week duration of clerkship in psychiatry was probably not enough to expose them to a real understanding of the practice of psychiatry, and would therefore not have had a marked influence on their preformed negative attitudes towards the profession.
In previous studies, some of the reasons suggested for the contrast between medical students' positive attitudes towards psychiatry and their failure to choose psychiatry as a future area articles of specialisation 26 have been that undergraduate teaching of psychiatry was disorganised; that the profession lacked scientific rigour, and was less financially rewarding than other areas of medical practice; that psychiatrists and the profession of psychiatry had less prestige and were less respected than other areas of practice in the eyes of the public; [26][27][28] and that psychiatric patients were hard to talk to and difficult to understand. 29spite our students' acknowledgement of the high intellectual demands of psychiatry, most were of the opinion that although the field was helpful in liaison practice, it had low status, was regarded by the public as having less prestige than other areas of medical practice, and was less financially rewarding.There is widespread stigmatisation of mental illness in Nigeria, 30 resulting in a generally negative perception of mental health issues.Both psychiatric patients and providers of mental health services therefore have an unfavourable image, and psychiatry is rated low as a profession by society.A mere 4 weeks' clerkship in psychiatry was not long enough to change the students' culturally enshrined negative beliefs.
However, in contrast to some negative opinions on the part of medical students on the scientific standard, efficacy of treatment, and biopsychological/ biomedical perception of psychiatric practice described in previous studies, [29][30][31] our students felt that psychiatry was an advancing scientific field of medical endeavour.This could partly be to their exposure to psychiatric  articles People with psychiatric problems are sometimes not voluntarily admitted to hospital, their next of kin (usually the accompanying relatives) giving informed consent on their behalf.However, involuntary confinement of persons labelled with psychiatric illness for punitive reasons 32 is not a feature of psychiatric practice in Nigeria, which explains why the students did not agree that psychiatrists abuse their power with regard to compulsory admission of patients.
In spite of the 6th-year students' 4 weeks' clerkship in psychiatry, many were of the opinion that psychiatrists were not clear, logical thinkers, and together with the 5th-year students said that they would feel uncomfortable when in contact with psychiatric patients.The short duration of the clerkship was probably not enough to allay their culturally imbibed 'fear of the unknown' with regard to the patients.In addition, the public attitude that 'healers of mentally ill persons are like their patients' could have prejudiced the students' opinion about psychiatrists not being clear and logical in thinking.
Inculcating the biopsychosocial ideology of illness model into the 1st-year and preclinical teaching curricula of medical students might affect doctors' future preference for psychiatry.There is a need to organise goal-orientated public enlightenment campaigns on mental health literacy (knowledge and beliefs about mental disorders that aid their recognition, management, or prevention).
Teaching of psychiatry should start from the students' preclinical days, and during this period much of the teaching should focus on the neuroscientific aspects of psychiatric disorders.Psychiatry clerkships should be more practically orientated than theoretical, exposing students to real-life experiences in the field.
Despite the relatively small population of students in the study, not all of them were able to fill in the questionnaire.It is therefore necessary to compare future findings from similar population groups with those of this study before generalisation of its findings.A future study on attitudes of preclinical and clinical medical students towards psychiatry may well reveal more than the findings of the present study.
and 6th-year (final-year) medical students at Bayero University, Kano, Nigeria, during February 2008.At that time the finalyear students had done their clerkship in psychiatry 2 months previously, and the 5th-year students had yet to start theirs.Data were collected using an abridged form of Balon et al.'s 1999 questionnaire, 25 based on a questionnaire used by Nielsen et al. in 1981.The abridged questionnaire was selfadministered, and consisted of 27 questions.The first 4 questions related to socio-demographic factors such as gender, age, academic year and choice of medical specialty.The remaining 23 questions were in five sub-sections and examined the attitudes of the students towards psychiatry with reference to the following aspects: (i) overall merits of psychiatry; (ii) efficacy; (iii) role and functioning of psychiatrists; (iv) possible abuse and social criticism; and (v) career and personal rewards.Respondentshad to either agree or disagree with each of the 23 items.The students were informed that the purpose of the research was to elicit their candid opinions about psychiatry as a profession, that participation was voluntary, and that there were no penalties for not participating.The students' informed consent was verbally solicited, as completing the questionnaire implied acceptance of consent.The students were assured that their responses would remain anonymous, since the questionnaire did not include any information by means of which they could be identified.All the students who were present in class on the day of the study and agreed to participate completed the questionnaire before their first morning lecture.Permission and assistance were obtained from the tutoring lecturer present on that day, and approval was obtained from the teaching hospital ethics committee before conducting the study.

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Preferred field of future specialisationTen (15.2%) of the 5th-year students chose internal medicine and 10 surgery as their preferred field of future specialisation, while 6 (24.0%) of the 6th-year students chose internal medicine and 5 (20.0%) surgery.Twelve (18.1%) of the 5th-year students said they would choose obstetrics and gynaecology, 8 (12.1%) family medicine, and 3 each (4.5%) paediatrics, neurology and diagnostic radiology.Only 1 5th-year student (1.5%) wanted to specialise in psychiatry.Sixteen (24.2%) of the 5th-years were undecided, and none chose anaesthesia or emergency medicine.
syndromes and observation of patients' responses to effective biological and psychological treatments during their clerkship.The 5th-year students, who had not yet done their clerkship, might have had similar attitudes because they knew of people who had responded well to psychiatric treatment.In not expecting clinical psychologists and social workers to be as qualified as psychiatrists in diagnosing and treating emotionally disturbed persons, the students were presumably aware that eligibility for a residency career in psychiatry requires successful completion of undergraduate medical education.In addition, the students would probably expect psychiatrists to have more authority and influence than other mental health professionals because doctors are the key figures in determining the plan of care for patients.There is a high degree of competition for residency positions in postgraduate training facilities in Nigeria.Because of better pay after attaining specialist qualification, many doctors opt for further training rather than to practice as non-specialists, and the number of doctors seeking postgraduate medical education currently outnumbers the spaces available in the postgraduate training facilities.Although our students did not view psychiatry as a popular choice, the number of doctors seeking careers in this field may therefore rise in the near future.

Table II . Responses on the role and functioning of psychiatrists from clinical medical students at Bayero University, Kano, Nigeria
*Not all subjects responded.

Table III . Reponses on career and personal rewards of psychiatry from clinical medical students at Bayero University, Kano, Nigeria
*Not all subjects responded.