How Intern Doctors View ‘Psychiatry and Mental health’?

Introduction: The knowledge and attitude prevailing during internship of medical education are likely to influence whole career. Psychiatry is seen differently, at times unrealistically. Such views might have adverse consequences. The objective of this study was to assess knowledge and views of intern MBBS doctors of B. P. Koirala Institute of Health Sciences, Nepal about ‘Psychiatry and mental health’. Material And Method: A cross-sectional semi-qualitative survey was done by explaining about the study, distributing a questionnaire and analysing collected samples of the interns. Results: Within study period, 50 respondents participated. Twenty percent respondents were female. One-third subjects were from Kathmandu valley, followed by other cities of Nepal and India. Two-thirds opted psychiatry posting, half to learn about it. About 25% considered psychiatry for career. Majority viewed psychiatry should integrate with other departments. Only few meant mental illness to be unremitting and chronic only, and considered mental patients dangerous and aggressive. More believed that majority of patients understand others’ feelings, attitudes and behavior; and can be productive if treated appropriately. A great majority felt that the management should be multi-sectorial and multi-dimensional. They expressed dissatisfaction about current position of mental health on national health-policy and advised public awareness as the most important step to change the situation. Conclusion: Intern-doctors of a tertiary-care teaching hospital with psychiatry teaching, in overall, have favorable attitude towards psychiatry and mental health.


INTRODUCTION
The knowledge and attitude of future medical doctors towards 'psychiatry and mental health' is important in many perspectives. [1][2][3] The positive attitude will help improve the quality of care of psychiatric patients, irrespective of their field. 4 Hence, medical education should strive to enhance the knowledge and promote the positive attitude about psychiatry and mental health. [5][6][7] It is the subject of study whether more positive attitude will increase the medical doctors willing to choose psychiatry as career. 3 To best of our knowledge, there are few studies from Nepal, particularly regarding the view of intern doctors towards 'psychiatry and mental health'. 8,9 With the hope that it will pave way to further studies, this study was carried out at B. P. Koirala Institute of Health Sciences (BPKIHS), one of the pioneer medical institutes and a tertiary care hospitals in Nepal, in 2008 to explore into how intern MBBS doctors view psychiatry, mental health and psychiatric patients.

MATERIAL AND METHOD
This is a cross sectional semi-qualitative institution based survey. A questionnaire (with the reference to 'attitude to Psychiatry 30' questionnaire 10 and with modification to suit local context and enhance the accuracy of the responses) was designed to elicit information regarding demographic data ORIGINAL ARTICLE (confidentiality maintained), attitudes towards psychiatry and mental health, the psychiatry posting, mentally ill people, their treatment and career choices. A pilot study was done among 5 intern doctors to examine its validity. The selfadministered questionnaire provided distracter sentences on different aspects of psychiatry and mental health. The subjects were supposed to choose 'right/ agree' or 'wrong/ disagree' and state the reason or whatever they feel on the distracter sentence. The questionnaire was distributed among 100 intern doctors with or without elective posting in the department of psychiatry in 2008 after an explanation about the study. Within the study period, 50 respondents returned the questionnaire. The potential respondents were reminded through phone call or personal communication 3 times at maximum over a period of 4 months to return the completed survey questionnaire. The responses/ statements of the subjects were analyzed and grouped into the most matching ones for better understanding. The data were analyzed using descriptive statistics.

RESULT
In total, 50 responses were received from intern doctors in the study period. Brahmins, indiginous Terai tribes and Mongols were the top 3 castes among the respondent interns. Twenty percents were female. Most of them were from cities, including Kathmandu and other cities of Nepal and India. (Table 1) The most common reasons for choosing medical education were: interest in medical career, family choice and service motive. Nearly two thirds of respondents were interested for elective posting in psychiatry and the common reasons for this were: to learn about the subject, career choice and interesting subject. (Table 2) Internal medicine, pediatrics and psychiatry were the most chosen subjects among the respondent interns for their career. Among those choosing psychiatry, the most common reason was interest in the subject and among those not choosing, the most common reason was lack of interest in the subject itself. (Table 3)  Majority of the respondent interns view psychiatry as a rapidly advancing medical specialty like any other, psychiatric service should be integrated with other medical services; and the treatment of mental problems needs collaboration of many sides, even though many thought that there are curative and specific medicines for many psychiatric disorders. Similar great majority were not satisfied with the current level of priority for mental health in national health policy of Nepal. They believe that it deserves a priority in health policy and public awareness is the most important strategy to change it. (Table 4) Health means wellbeing, not only of body according to 56% respondents. A great majority opined that nobody is immune to mental illness, mental illness does not always mean chronic and unremitting ones and they are not transmitted as infectious diseases. Many believed that mental illness is not only one, it is not less common in developing countries and villages, majority of suicidal people are psychiatric patients, and physical symptoms are common among psychiatric patients too. (Table  5) All subjects responded 'no' about 'as mental illness is caused by witchcraft, allopathy will be harmful'. Almost all were against the statement that 'mental illness does not exist or is rare'. Great majority believed mental illness to be the result of bio-psycho-social factors. Almost half of the respondents thought substance related disorder to be habit or weakness of will power and the half opposed the idea. (Table 6) Most of the respondents indicated that all psychiatric patients are not dangerous and aggressive, these patients do understand others' feelings, attitudes and behavior, and they may live productive life, with treatment. (Table 7) All responded 'no' to the statement 'counseling means to talk'. A great majority believed that electroshock therapy is safe and effective treatment method and management of mental illness is multi-dimensional effort. Nearly threefourths viewed that treatment of mental illness is equally effective as that of physical illness. (Table 8)   Other/ no answer (%) 1 Mental illness does not exist or is rare Bio-psycho-social causation of mental illness is holistic approach 41 (82) 4 (8) 5 (10) 3 As mental illness is caused by witchcraft, allopathy will be harmful.
Substance use disorder is a habit or weakness of will power.   7 Shakya et al about electroconvulsive therapy (ECT) also positive, 10 Chadda et al found favorable changes in awareness about psychiatry among the 3 rd year MBBS students with questionnaire pre and post 2-week teaching program 11 and Pandey et al reported the 4 th year MBBS students to favor the vertical integration of the subject. 12 Overall attitude towards mental illness and psychiatry was found either positive or neutral among medical students and interns (27.7% of the total) in a medical college of Nepal. 8 Other medical college student and intern study revealed positive attitude in terms of benevolence and mental hygiene, and neutral in terms of social restriction of mentally ill and interpersonal relationship as a cause of mental illness. 9 Another study reported overall positive attitude among the 4 th year MBBS students of a University hospital in Kathmandu. 14 Current study was carried out to assess the attitude of the intern doctors who would soon work as a doctor.

(44) 25 (50) 3 (6)
Knowledge, attitude and practice are close and interrelated correlates. 7 Hence, in order to assure the adequate care for mentally ill people, it should be a fundamental aim of medical education to promote positive attitudes towards the mentally ill and psychiatry by promoting essential and adequate knowledge, skills and competence. [5][6][7] Well designed, intensive curriculum with adequate hours of exposure have been reported to be effective in enhancing positive attitude 12,14,16 whereas the opposite may even worsen the attitude. 17 A study carried in medical students of different levels revealed decreasing number of medical students willing to join psychiatry in later year (15/61 initially which changed to 11 later). 18 In BPKIHS, MBBS students attend lectures on various topics on 'general psychiatry', 'clinical psychiatry' and 'psychiatry and other specialities' in different semesters; expose themselves to out and inpatient department during posting and in internship, they are free to choose psychiatry as a 2 week-optional posting. Study of knowledge and attitude of intern doctors, hence may reflect the overall view on psychiatry of the MBBSproduct of the institute after the whole training. BPKIHS has not only been providing service to Nepalese and many Indians patients, 19 but also education to Nepalese and also Indian and other students. 20 Though the institute provides reservation for the students of various categories, castes and regions of the country; the representation of female students, unpriviledged ethnic groups and rural settings were smaller among the respondents. This finding is consistent with another study among medical students of the institute. 20 We included a question about the reason for choosing medical education/ career which showed that interest in medical field, family choice, inclination to serve people, inherent noble nature of the profession were the main expressed ones. To a question about the motive of the psychiatry posting during internship, a significant number of the respondents considered for it and many wanted to learn more about the subject before exposure to real service field. And, some had interest and even considered for career choice. Psychiatry, as a specialty, is frequently seen with different notions, inclinations and feelings, at times negative. 7 It has been a subject of less interest and choice among medical students in many places 21 though some report it to be among promising choices. 16 The recruitment in this field has been a serious concern in many places, including developed countries. It remains to be investigated, however, whether an improvement in the attitudes of medical students towards the psychiatry discipline is sufficient to increase the number of students who would like to become psychiatrists 3 or whether other factors are more deciding such as: career opportunities, conditions of further education, or income potential. 18,22,23 Though not conclusive, but there is a strong suggestion from many studies that it may play an important role in increasing the chance of psychiatry being chosen as career among medical students. 5,6,14,16 This study revealed a welcome sign that many of these intern doctors, equal in number to those choosing one of the most desired subjectpediatrics, 16 considered psychiatry for future career. Internal medicine was the subject most number of respondents chose. Psychiatry and pediatrics stood second in the rank. Interest of the respondents was the most expressed reason for choosing it and again lack of interest in it, i.e. interest in other field was reason for not choosing it for career. Many respondents did not answer on both the questions and some regarded psychiatry as a difficult subject. It needs a separate study to make a definite comment since intensive look may reveal different findings. 22,23 In this study, a self designed questionnaire was used which was prepared keeping the 'ATP-30' 10 as a reference and where responses were to be filled in questions about socio-demographic variables and open ended questions, and to be chosen from among 'agree/ right', 'disagree/ wrong' and 'other-to be specified' with the reason or whatever they felt on the distracter sentence about the knowledge and attitude to psychiatry.
We suppose this type of questionnaire design would provide scope of including some local context, incorporate questions to assess knowledge domen as well, simplify the analysis process and also elicit the nearest response of the subjects. As a specialty, psychiatry is one of the most rapidly progressing medical fields in the view of majority of the intern doctors. Though some respondents expressed psychiatric services should be apart from main stream medical service, majority were in the favour of its integration into a general hospital. This concept has been viewed as beneficial to reduce stigma about mental illness, enhance consultation liaison and better access. Their disagreement about 'management of psychiatric disorders as sole responsibility of psychiatrists' reflects their realistic emphasis on the role-play of other nonpsychiatrist professionals, family and society. Nearly one-fourth appeared to be in dilemma about specific and curative psychotropic medicine though majority agreed that there are curative and specific psychotropic medicines. A great majority voiced in the favor of the due priority for mental health in national health policy of Nepal. In this way, there is optimism that these doctors will be promoters of mental health, irrespective of their fields. And, raising awareness was the first and most important strategy to bring change in current status of Nepalese mental health, according to them. So, in overall the responses were comparable to the post-teaching responses of other studies among medical students 12,15,16 and nearer to the current medical understanding. A majority the subjects strongly agreed that nobody is immune to mental illness, psychiatric disorders are not always chronic and unremitting and similarly believed that mental illness is not transmitted like communicable diseseas. A sizeable number of respondents voiced that health means well-being of body though majority expressed the notion of physical, mental and social well-being as indicated by the WHO. Similar proportion of the responses were in dilemma about the prevalence of mental illness in developing countries and villages, the concept of mental illness as a single disease and prevalence of physical symptoms in psychiatric disorders. These responses indicated some scope of intensive improvement in psychiatry teaching with clarification of myths and misconcepts among medical students. However, it is noteworthy that the study was carried out during internship, long after their teachings and possibly postings for many. Nearly all agreed that mental illness do occur and disagreed that they are caused by witchcraft and sin, and medical treatment is detrimental. A majority were in the favor of the idea that biological, psychological and social factors all play in the causation of mental illness. Slightly less than a half of the respondents opined that substance use disorder is a habit or weakness of will power though half were against the idea. The later needs to be addressed well during the teaching and training. The responses regarding their attitude to psychiatric patients were also largely positive. A majority strongly expressed that psychiatric patients are usually not dangerous and aggressive, they do understand others' feelings, attitudes and behaviour and they can live productive life, with appropriate treatment. Some of the interns indicated that treatment of mental illness never ends and they are unremitting and similar number expressed doubt about the equal effectiveness of treatment of mental illness as physical illness. But larger number viewed otherwise. The response about the safety and effectiveness of the ECT was remarkably in favor, consistent with the attitude study of ECT among nurses of the same institute. 11 It is noteworthy that all interns were aware about the concept of counseling which cannot be equated with simple talk. It is again welcome and positive attitude of these young doctors that they view the management of these disorders is a multi-dimensional effort.

Limitations
We could collect only a half the number of the distributed questionnaires because of different reasons such as many were posted out side the institute. The sample size was small. Though we tried to distribute the questionnaires among all interns both posted and not chosen for posting in psychiatry, the sample may be biased possibly because we might have collected the responses from those coming into contact and those who were interested in Psychiatry and mental health. And, some of the distracter sentences might not have been understood though there was a space for clarification in all questions.

CONCLUSION:
A significant number of the interns had psychiatry in mind for their future career. Intern doctors, in majority view psychiatry like other medical subjects: advancing; with curative and specific treatment strategies; and hence, to be integrated into and seen as an important component of health system. They view psychiatric disorders, in greater part like other medical illnesses: all being vulnerable, with many types, bio-psycho-social causation, safe and effective treatments, possibility of complications if not managed properly and in time. They, in over all, have realistic vision regarding the management of the mentally ill: safe and effective reliably, the duration and type of management depending upon type of illness. Public awareness and prioritization at national health policy are the steps to change the current state of negligence on mental health according to their suggestions. As a whole, intern doctors of this institute with psychiatry teaching and posting have positive attitude to 'psychiatry and mental health'.