ÖZET:
Tıp fakültesi öğrencilerinin psikiyatriye karşı
tutumları ve aleksitimi ile olası ilişkisi
Amaç: Psikiyatri branşı, son yıllarda tüm dünyada mezu -niyet öncesi tıp eğitiminde büyük önem kazanmıştır. Tıp öğrencileri arasında psikiyatriye karşı tutumlar gelişmiş ve gelişmekte olan ülkelerde yoğun şekilde araştırılmak -tadır. Psikiyatriye karşı tutumlar ve ihtisas için psikiyatri uzmanlığının tercih edilmesi demografik, kişilik ve sosyal değişkenler gibi birçok etmen tarafından belirlenmekte -dir. Bu çalışmada tıp fakültesi öğrencilerinin psikiyatriye karşı tutumları ve aleksitimi ile olası ilişkinin araştırılması amaçlanmıştır.
Yöntem: Bu çalışma kesitsel olarak tasarlanmıştır. Çalışma örneklemi 2013-2014 akademik eğitim-öğretim yılına ait 1. sınıftan (n=85) ve 2. sınıftan (n=73) toplam 158 prekli -nik öğrencisi ile 5. sınıftan (n=39) ve 6. sınıftan (n=58) top -lam 97 klinik öğrencisini kapsamaktadır. Çalışmaya dâhil edilen öğrencilere Attitudes Towards Psychiatry (ATP-30), Toronto Aleksitimi Ölçeği (TAS-20) ve sosyodemografik veri formu uygulanmıştır.
Bulgular: Çalışmaya katılanların ortalama ATP puanı 106,07 (sd=13,05) bulunmuştur. Çalışmamızda erkek öğrencilerin ATP puanları kadın öğrencilere göre anlamlı derecede daha yüksekti (p=0.001). Öğrencilerin psiki -yatriye karşı tutumları ile akademik yıl arasında negatif anlamlı ilişki tespit edilmiştir (p<0.001). Preklinik ve klinik gruplar ATP ölçeğinden, istatistiksel olarak anlamlı farklılıklar bulunan maddeler yönünden karşılaştırıldığında klinik grubun sekiz maddeden birisi dışındaki tüm olumsuz maddelerden preklinik gruba göre anlamlı derecede daha yüksek puanlar aldıkları saptanmıştır (p<0.05). Son olarak aleksitimik öğrenciler ile aleksitimik olmayan öğrenciler arasında toplam ATP puanları yönünden anlamlı bir farklılık saptanmamıştır (p>0.05).
Sonuç: Afyon Kocatepe Üniversitesi Tıp Fakültesi öğrenci -leri psikiyatriye karşı orta düzeyde olumlu tutuma sahip -tiler. Erkek öğrenciler kadınlara göre daha olumlu tutuma sahipti. ATP ölçek puanı ile eğitim yılı arasında negatif bir ilişki saptandı. Çalışmamızdaki katılımcılar Türkiye’deki tüm tıp öğrencilerini temsil etmemektedir, bulgularımızın test edilmesi için geniş örneklemler üzerinde kapsamlı çalışmalar yapılmasını öneriyoruz. Klinik psikiyatri ile daha erken temas, olumlu eğitici rol modelleri ve etkili eğitim yöntemlerinin tıp öğrencilerinin psikiyatriye karşı tutumla -rında olumlu değişikliklere yol açacağını düşünmekteyiz.
Anahtar sözcükler: tıp fakültesi öğrencileri, psikiyatriye karşı tutum, aleksitimi
Journal of Mood Disorders 2015;5(4):157-63
ABS TRACT:
Attitude towards psychiatry and its possible
association with alexithymia among medical
students
Objective: Psychiatry has gained an increasing importance in medical undergraduate curricula around the world in the last few decades. Attitudes towards psychiatry (ATP) among medical students have been studied extensively in developed and developing countries. ATP and a career choice in psychiatry appear to be associated with various factors including demographics, personality, and social variables. In the present study, our aim was to investigate attitude towards psychiatry and its possible association to alexithymia among medical students.
Methods: The study design was cross-sectional. Study sample consisted of first (n=85) and second (n=73) year preclinical students, fifth (n=39), and sixth (n=58) year clinical students during 2013–2014 academic year. All participants were asked to complete the Attitude Towards Psychiatry 30 (ATP-30), the 20-item Toronto Alexithymia Scale (TAS-20), and a socio demographic query form. Results: The mean ATP score for respondents was 106.07 (SD=13.05). Results revealed that male students had a significantly more positive attitude than females (p=0.001). It was found that there was a negative linear relationship between students’ ATP score and academic year (p<0.001). Students who obtained significantly higher scores on the ATP scale were those who did not intend to select psychiatry as their career (p<0.001). When items from the ATP scale showing significant difference (p<0.05) between clinical and preclinical groups were evaluated, overall eight items except one clinic group had higher scores on the negatively phrased items. Finally, we found no significant difference in the ATP scores between alexithymic students and non-alexithymic students (p>0.05).
Conclusion: Afyon Kocatepe University medical students have a moderate positive attitude towards psychiatry. Male students had more positive attitude than females. Interestingly, there was a negative linear relationship between student’s ATP scores and their academic year. Our results should not be seen as representative of whole medical students in Turkey, but as indicative of current trends. So, further national representative sample research is needed to verify our findings. Early contact with psychiatric practice, positive role models and mentors, and developing effective educational approaches could improve perceived value of specialty and positive attitudes towards psychiatry.
Key words: medical students, attitudes towards psychiatry, alexithymia
Journal of Mood Disorders 2015;5(4):157-63
Attitude Towards Psychiatry and Its Possible
Association with Alexithymia Among Medical
Students
Ahmet Hamdi Alpaslan
1, Ugur Kocak
2, Kerem Senol Coskun
3, Omer Ozbulut
3, Arda Yesil
31Afyon Kocatepe University, Faculty of
Medicine, Department of Child and Adolescent Psychiatry, Afyonkarahisar-Turkey
2Afyon Kocatepe University, Faculty of
Medicine, Department of Forensic Medicine, Afyonkarahisar-Turkey
3Afyon Kocatepe University, Faculty of
Medicine, Department of Psychiatry, Afyonkarahisar-Turkey
Ya zış ma Ad re si / Add ress rep rint re qu ests to: Ahmet Hamdi Alpaslan,
Afyon Kocatepe University, Faculty of Medicine, Department of Child and Adolescent Psychiatry, Afyonkarahisar-Turkey Elekt ro nik pos ta ad re si / E-ma il add ress: ahmethamdialpaslan@yahoo.com Ka bul ta ri hi / Da te of ac cep tan ce: 20 Nisan 2015 / April 20, 2015
Bağıntı beyanı:
A.H.A., U.K., K.S.C., O.O., A.Y.: Yazarlar bu makale ile ilgili olarak herhangi bir çıkar çatışması bildirmemişlerdir.
Declaration of interest:
INTRODUCTION
Psychiatry as a branch of medicine has showed great progress in recent decades. Neurobiological and social science research has improved our understanding of disorders such as major depression and schizophrenia and improved our capacity to provide cost-effective treatment and care. Better understanding and more effective interventions might be expected to improve attitudes, among general population and among health professionals, towards mental illness and psychiatry. However, stigma and unfavorable attitudes towards psychiatric patients and mental illness continue to widely exist among general population, medical students, and the medical professionals (1).
Attitude was defined by Rezler as ‘‘an emotionally linked, learnt belief around an object or situation predisposing one to respond in some preferential manner’’ (2). Attitudes towards psychiatry (ATP) and psychotherapy among medical students as well as towards the mentally ill form the basis of their future actions as medical doctors (3) and have been studied since the 1960s (4). In 1982, Burra et al. who validated the ATP-30 found that positive attitude changes towards psychiatry in medical students in third and fourth years of their training were related to their exposure to psychiatry. The change took place among those students whose training consisted primarily of clinical aspects of psychiatry with a considerable amount of patient contact (5).
A positive attitude towards psychiatry is important in all branches of medicine as it might make doctors more attuned to the psychological needs and comorbidity which occur in patients presenting to all medical specialties (6). Several studies have found that attitudes towards psychiatry among medical students become more favorable after their undergraduate psychiatric attachments (5-8). While many studies indicate that increased more participation in psychiatric practice at medical school has a favorable influence on attitudes towards psychiatry and a career choice of the discipline, others imply that such participation could be counterproductive or have a minimal effect (9-11).
Alexithymia is characterized by difficulty in identifying and describing feelings (affective factors), by concrete and externally oriented thinking (cognitive factors). In general, the dream content of alexithymic individuals is very restricted and reflects their daily life. Their mental activities
are concrete, without emotion, without unconscious fantasies and focus on the present moment (12). In previous studies, years of training, and related personal factors including age, gender, nationality, interest in psychiatry as a career, and their association to ATP were investigated. In the present study, our aim was to investigate attitude towards psychiatry and its possible association to alexithymia among medical students.
MATERIALS AND METHODS
Participants
The study design was cross-sectional. It was conducted among medical students aged between 17 and 29 years (n=270) at Afyon Kocatepe University (AKU, Turkey), between January and March 2014. First (n=85) and second (n=73) year students had not yet received any psychiatric training, while fifth (n=39) and sixth (n=58) year students who completed both theoretical and practical training in psychiatry were included in the study. The recruitment process was performed in classrooms. After oral information was presented and consent was obtained, all participants were asked to complete the Attitude Towards Psychiatry 30 (ATP-30), the 20-item Toronto Alexithymia Scale (TAS-20), and a Socio demographic query form. Twenty-five students (n=15) were excluded from the study because of missing data, resulting in an analytical sample of 255 students. The study was approved by the Local Ethical Committee for Clinical and Laboratory Studies at the AKU School of Medicine.
Measures
Socio demographic Query Form: We designed a brief demographic and career interest questionnaire which was used in obtaining data such as age, gender, class, type of family, parental occupation, monthly income of the family and preferred specialty choice following graduation.
The 20-item Toronto Alexithymia Scale (TAS-20):
TAS-20 are provided by Bagby et al. (13), and a score of 61 or higher is considered to be within the alexithymic range. The Turkish version of the TAS-20 was used (14). The Cronbach’s alpha coefficient for the total TAS-20 scale was 0.78.
The Attitude Towards Psychiatry (ATP30): The ATP is a 5-point Likert-type scale designed and validated in Canada by Burra et al. (5). The scale consists of 30 positively and negatively phrased items that measure the strength of the respondent’s attitude to various aspects of psychiatry. The score of each positively phrased item was converted by subtracting it from 6. The ATP score is the sum of the total scores for positive and negative phrased items. A high score on the scale indicates a positive attitude towards psychiatry (maximum=150, minimum=30, logical neutral point=90). The ATP scale was translated to Turkish and back translated to English by two psychiatrists. A third psychiatrist checked the final version for clarity. The final draft was pilot tested on 10 medical students prior to its application.
Statistical Analysis
The data obtained were evaluated using the Statistical Package for the Social Sciences (SPSS 19 for windows; SPSS Inc, Chicago, IL) software. Descriptive statistics (means and standard deviations as appropriate) and percentages were computed for the study sample on demographic variables and all psychometric scales. To compare the characteristics of groups, t-test was performed for continuous and categorical variables. Differences were considered significant at p values less than 0.05.
RESULTS
In the present study, a cross sectional design was used. Study sample consisted of first (n=85) and second (n=73) year preclinical students, fifth (n=39), and sixth (n=58) year clinical students during 2013–2014 academic year. A total of 255 students (42% n=107 male, and 58% n=148 female) aged between 17 and 29 (20.90±2.24) were included in the study. When students’ career choices were evaluated, 62 students (24.3%) selected surgical branches, 61 (23.9%) undecided, 23 (9%) psychiatry, 14 (5.5%) gynecology, 14
Tab le 2: Scores obtained on the ATP-30 scale in terms of gender, class by year, alexithymia and intending to select psychiatry as a career
ATP-30 Scores t p
(Mean±SD)
Gender
Female 103.41±12.88 3.218 0.001**
Male 108.73±13.22
Class
1-2 107.59±11.93
5-6 102.47±14.69 2.892 0.004*
Select psychiatry as a career
Yes 93.39±12.69 4.847 <0.001**
No 106.86±12.71
Alexithymia
Alexithymic 106.706±11.367 0.826 0.409
Non alexithymic 105.200±13.979
*p<0.05, **p<0.001
Tab le 1: The distribution of students’ gender by class year and career choices
n %
Gender
Female 148 58.0
Male 107 42.0
Class
1 85 33.3
2 73 28.7
5 38 14.9
6 59 23.1
Career choice
Surgery branches 62 24.3
Undecided 61 23.9
Others 29 11.4
Psychiatry 23 9.0
Family medicine 16 6.2
Gynecology 14 5.5
Dermatology 14 5.5
Internal medicine 13 5.1
Pediatrics 10 3.9
Radiology 5 2.0
Physiotherapy 5 2.0
(5.5%) dermatology, 13 (5.1%) internal medicine, 10 (3.9%) pediatrics and 29 selected (11.4%) other branches. Table 1 shows the distribution of students’ gender by class year and career choices.
Table 2 shows the comparison of the students’ scores obtained on the ATP-30 scale in terms of gender, class year, alexithymia and intending to select psychiatry as a career. The mean ATP score for participants was 106.07 (sd±13.05). The results revealed that male students had a significantly more positive attitude than females (p=0.001). It was found that there was a negative linear relationship between students’ ATP score and academic year (p<0.001). Surprisingly, medical students who obtained significantly higher scores on the ATP scale were those who did not intend to select psychiatry as their career (p<0.001). Finally, there was no significant difference between the ATP scores of alexithymic (n=58, 22.7%) and non-alexithymic students (p>0.05).
Table 3 shows the items from the ATP scale which have significant difference (p<0.05) between clinical and preclinical groups. Overall, fifth and sixth year students had higher scores on eight items, among those which seven had negative phrases except for the item “These days psychiatry is the most important part of the curriculum in medical school”.
DISCUSSION
Attitude is defined as a hypothetical constitution that represents an individual’s like or dislike for an item. Attitudes are positive, negative or neutral views of an ‘attitude object’, i.e., a person, behavior or event. Attitudes
come from judgments and it comprises of affective, behavioral and cognitive components (15). In the present study, we aimed to explore attitude towards psychiatry and its possible association to alexithymia among medical students.
Our findings showed that AKU medical students have a moderate positive attitude (mean ATP score=106.07±13.05) towards psychiatry. Male students had significantly more positive attitude than females. Contrary to our findings, some previous studies showed a significantly more positive attitude among female students (16,17). However, these results could not be demonstrated in Germany (18). Today’s students, independent of their gender, seem to set a higher value on work–life balance, spending time with their families, friends and hobbies, which require a more flexible approach in their professional lives (19-21). We think out that, compared to the previous years there is a more general shift in priorities among medical students in our country.
In the present study, it was found that there was a negative linear relationship between students’ ATP score and their academic year. Burra et al. who validated the ATP-30 found that positive attitude changes towards psychiatry among medical students in the third and fourth years of training were related to their exposure to psychiatry (5). However, several studies suggest that clinical attachment is an important factor in recruitment to psychiatry and that it might positively affect attitudes to psychiatry, but this may be transient (22,23). An explanation for the differences between our study and others could be that clinical problems discussed in medical rounds are few and the time allocated for clerkship is shorter than similar programs in other universities. Medical students spend more time on general
Tab le 3: Means of items on the ATP 30 questionnaire which showed significant difference between groups
Class 1-2 Class 5-6
(Mean±SD) (Mean±SD) t p
3. Psychiatric patients are interesting 2.03±0.95 1.77±0.65 2.506 0.013*
6. Psychiatrists seem to talk nothing but sex 3.83±0.93 4.34±0.85 4.411 <0.001**
16. Most of the so-called facts in psychiatry are vague speculation 2.84±0.89 3.12±0.96 2.390 0.018*
17. Psychiatry has very little scientific information to go on 2.98±0.95 3.45±1.03 3.655 <0.001**
18. Psychiatry is so unscientific that even the psychiatrists cannot
agree to scientific basis 2.94±1.05 3.39±1.10 3.251 0.001**
21. These days psychiatry is the most important part of the
curriculum In medical school. 2.36±0.93 2.10±0.98 2.098 0.037*
22. Psychiatry is so amorphous that it cannot be taught effectively 2.79±1.11 3.23±1.09 3.046 0.003*
29. Psychiatric hospitals little more than prisons 3.03±1.05 3.45±1.29 2.746 0.007*
medicine and surgical branches in their fifth and sixth years. This might have affirmed the medical students’ self-image as ‘disease-oriented’ doctors and hardened attitudes away from a specialty such as psychiatry that emphasizes both a biological and psychological approach. It is possible that attitudes towards other specialties also decay after graduation. Whether the decrease of the scores by the time of education in the ATP score might be related to diminished interest in psychiatry or to increase in interest in other fields of medicine and surgery.
Nine percent of the students intended to choose psychiatry as a future specialty, which implies that psychiatry does not appear to have a bad reputation. Surprisingly, students who obtained significantly higher scores on the ATP scale were those who did not intend to select psychiatry as their career. Similar patterns of dissonance have been reported from Israel (24), the United States (25) and Pakistan (26). Various explanations have been proposed for this phenomenon. According to one of the studies, the teaching of psychiatry at the undergraduate level was disorganized or not done properly. Some other studies have reported that psychiatrists are perceived to earn less money, to be less respected, and to have less prestige compared to other specialists (24, 27). Nevertheless, psychiatry has been rated higher than any other discipline on the intellectual challenge (10). Although studies mentioned so far generally reported that disparity between a positive attitude and career choice exists, the actual levels of inconsistence vary between studies and countries. One probable explanation for this wide variation could be the differences in the coverage level and duration of psychiatry course at the time of surveys.
When items from the ATP scale showing significant difference (p<0.05) between clinical and preclinical groups were evaluated, fifth and sixth year students had higher scores on eight items among those which seven had negative phrases except one. In general, the negative theme including perceptions that psychiatry is unscientific, non-enjoyable, and does not make use of medical training. Several studies have found that attitudes towards psychiatry among medical students become more favorable after their undergraduate psychiatric attachments (5-8). The evidence to whether or not this improvement in attitude is maintained is, however, equivocal. This effect declined significantly over time during undergraduate training (23,28). Baxter et al. (2001) found that the improvements in attitudes towards psychiatry after fourth-year had significantly decayed during the final year
and then reduced to the level below prior to their clinical attachment (23). At this stage, importantly, we suggest that the method of teaching at medical school (problem-based versus traditional, didactic learning) may impact on students’ attitudes. In addition, psychiatric practices seem to be highly beneficial since it has been demonstrated that direct contact with mentally ill patients have a greater effect on medical laymen than didactic concepts with respect to change in attitudes (29). Students should therefore continuously undergo training in knowledge-based psychiatry as well as clinical ptactice training in psychiatry throughout their medical education. Negative attitudes towards psychiatry based on incorrect assumptions could be counterbalanced by this way (25).
Another goal of our study was to explore a possible relation between alexithymia and ATP. However, we found no significant difference in the ATP scores between alexithymic and non-alexithymic students. To the best of our knowledge, this is the first study that has evaluated the relationship between ATP and alexithymia among medical students. Alexithymic individuals have affective dysregulation; they are unable to self-soothe and manage their emotions because of a lack of awareness of emotions (30,31). Alexithymic subjects are perhaps unable to express themselves correctly because of their difficulties in cognitive processing of emotions. Some authors postulate that alexithymia was a socially defined concept rather than only a psychological phenomenon. From this point of view, it could be stated that occurrence of alexithymic characteristics in individuals is a result of learning related with the characteristics of socio-cultural environment in which they live (32). The probable role of alexithymia in attitudes towards psychiatry should be tested in future studies.
and management of students’ negative attitudes towards psychiatry.
In conclusion, AKU medical students have a moderate positive attitude towards psychiatry. Male students had a significantly more positive attitude than females. Interestingly, there was a negative linear relationship between student’s ATP scores and their academic year, students who obtained higher scores on the ATP scale were those who did not to intend to select psychiatry as their career choice. Finally, no significant difference was found in the ATP scores between alexithymic and non-alexithymic
students. Our results should not be seen as representative of whole medical students in Turkey, but as indicative of current trends. So, further national representative sample research is needed to verify our findings. We believe that early contact with psychiatric practice, positive role models and mentors, developing effective educational approaches such as training consisted primarily of clinical aspects of psychiatry with a considerable amount of patient contact, problem based psychiatric teaching could improve perceived value of specialty and positive attitudes towards psychiatry.
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