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Karthik MS, Vikas Prabhav M, Balakrishnan R, Sathianathan R

Aim This current study was conducted with the intention of assessing
attitudes toward mental illness and correlating the same knowledge in
regards to the same among medical doctors.

Materials and methods A cross sectional study design was used with
the sample of doctors obtained from medical officers, postgraduates,
resident doctors and consultants from various specialties and subspecialities employed at various hospitals and clinics in Chennai via
simple purposive sampling. The AMIQ (Attitudes toward mental illness
questionnaire) was employed to assess attitudes. A modified version of
the knowledge questionnaire used by the NMHP (national mental health
programme) was utilized to assess knowledge. Demographic variables and
information in regard to experience and field of expertise were also

Results and conclusion we found that the attitude toward heroin use (6.61), and schizophrenia (-3.26) were predominantly negative, however
depression (3.14) was perceived better. The study also revealed sub
optimal knowledge levels especially in the management of mental illness.

A strong positive correlation was noticed between the knowledge and

attitude scores, suggesting that measures aimed at improving attitudes
and removing stigma will have a positive impact on effective healthcare
for the mentally ill.

In the Indian perspective, it would be unrealistic to try and solve problems
in mental health delivery systems with the services of psychiatric
specialists alone

considering the calculated average national deficit of

psychiatrists is 77%. Expectedly, general practioners and non-psychiatrist

specialists have a major role to play in the management of mental illness.
Prior studies have already pointed out the lacunae in the undergraduate
medical education system in India especially in regard to psychiatry 8. An
apparent inability to correctly identify psychiatric ailments is often
compounded by the social stigma attached to mental illness. People tend
to have strong beliefs about the mentally ill, and many of these concepts
complicate diagnostic practices and treatment outcomes. The lack of
substantial knowledge concerning mental disorders is conducive to the
emergence of stereotypes. In turn, these stereotypes aversively affect
treatment and outcomes in people with mental disorders. Wolff et al.
hypothesized that negative attitudes toward the mentally ill are fueled by
a lack of knowledge9. A lack of knowledge would lead to poor patient
outcomes. Thus studying the current levels of knowledge and attitudes

would help direct future training and intervention methods that would
eventually lead to effective mental health care.

Aims and Objectives

The primary aim of our study was the assessment of knowledge and
attitudes in regard to mental illness among medical doctors who have had
no prior formal training in psychiatry. An additional objective was to
correlate knowledge and attitude scores. Further we also wanted to study
the effect of demographic factors and experience atop knowledge and

Materials and methods

This cross sectional study was conducted at the department of psychiatry,

Sri Ramachandra medical college and research institute (SRMC&RI),
Chennai. Institutional ethical committee approval was obtained prior to
conduct of the study. Medical professional was restricted to doctors who
had completed their MBBS, at minimum.

The sample included medical

officers, residents, postgraduates and consultants from SRMC&RI and

various other clinics in Chennai obtained via purposive, maximum
variation sampling. All doctors with prior formal training in psychiatry
beyond the scope of the undergraduate curriculum were excluded.

Tools and Instruments

Data was collected via a three part questionnaire. The first part recorded
socio demographic information that included age, sex, marital status,
religion, specialty and designation, years of experience and information on
prior psychiatric exposure. The knowledge questionnaire

consisted of

seven case vignettes (seizure, mania, schizophrenia, anemia, anxiety,

mental retardation and delirium) developed and validated by the Indian
Council of Medical Research evaluate the training given to primary health
center medical officers in psychiatry as part of the National Mental Health
Program (NMHP). The scoring key was slightly modified to include newer
therapeutic measures.
The answers were scored in the format below.

Drug of choice and dosage

Side effects of drugs and management of side 1+1
Other available drugs, dosage, side effects & 1+1+1
Management of side effects
Non-pharmalogical management
Advice to be given about illness, treatment and 1.5
Indications for referral
Total Score
The Attitudes were measured with the Attitudes to Mental Illness
Questionnaire (AMIQ), a brief self-completion questionnaire with good
psychometric properties. Respondents were asked to read a short vignette
describing one of seven imaginary individuals and then answer five
questions. The questions are scored on a 5 point Likert scale (Maximum
+2 and minimum -2) with neutral and I dont know being marked zero.
The score for the five questions was added giving a total score for each
vignette was between +10 and -10.

Statistical Analysis
Independent sample Mann-Whitney U test and the Independent sample
Kruskall-Wallis test by ranks were used to compare the distribution of
knowledge and attitude scores among groups. Spearmans rank order
correlation was used to draw parallels between the demographic variables
and the attitude and knowledge scores.

Pair wise comparisons were

performed using the Dunns multiple comparison test.

Out of the participants in our study MPs who had completed or are
pursuing post-graduation contributed substantially to the study population
(N=111). Among those who had completed their post-graduation,
specialists in internal medicine were the most represented population
(N=15), there was a slight over representation on of junior consultants
(N=45) when compared to senior consultants (N=34). 52.8% (N=66) had
completed their post graduate training, 25.6% (N=32) were post graduate
trainees, 11.2% (N=14) had completed their MBBS and 10.4% (N=13) of
our participants were pursuing or had completed subspecialty degrees. A
majority of the MPs who participated in our study were middle aged
males; the mean age was 36.19 (8.169) years with the youngest
participant being 22 years old and the eldest being 57 years old. There
were more males (N=73) when compared to females (N=52).
Attitude Scores


Heroin Use


Std. Deviation
-6.6080 2.782



3.1440 3.318

Alcohol use


0.6640 3.775



-3.2560 2.833

Total AMIQ score


-6.0560 8.883

Heroin use was the most negatively perceived (-6.6080 2.782) of the
represented mental illnesses, however participants displayed a neutral








schizophrenia was also predominantly negative (-3.2560 2.833).

Attitude towards depression was predominantly positive (3.1440 3.318).
A Correlation Coefficient of 0.268(p<0.005) indicated that with increasing
age, attitudes toward mental illness also improved. Males had a better
attitude scores toward depression (3.553.51) and schizophrenia (2.822.70) when compared to females (2.582.97,-3.872.92) (p<0.05).
Males also had a better cumulative attitude scores when compared to
females (-4.819.45 when compared to -7.817.78). There appeared to
be a better attitude toward depression (3.823.16) and schizophrenia (2.872.48) among married MPs when compared to unmarried MPs
(2.123.48 and -4.003.10 respectively). Married professionals also had a








professionals (-8.568.72). Pairwise comparisons revealed statistically

significant differences between medical officers and senior consultants
(p<0.05) and between junior consultants and senior consultants (p<
0.05). Senior consultants and those professionals with over 5 years of
experience in their fields had better attitudes toward mental illness.

The maximum obtainable score per vignette was 12. Out of the vignettes,
participants obtained least mean knowledge scores in mania (4.53 3.09)
and schizophrenia (4.50 2.09). The participants obtained highest mean
scores in vignettes describing seizures (9.24 1.33) and anaemia (7.28
4.29). Participants obtained a mean score of 6.932.24 in the anxiety
vignette and 6.821.94 in the intellectual disability vignette. All the
participants diagnosed seizure disorder correctly. Participants had trouble
diagnosing alcohol induced psychosis (52%) and mania (54.4%). It was
encouraging to see that schizophrenia was well recognized (82.4%), but
the responses to the other questions based on pharmacological and nonpharmacological management in the schizophrenia vignette were less
than average (16.8% and 17.6% respectively). The answers also reflected
poor knowledge about both pharmacological and non-pharmacological
management of other mental illnesses such as mania (26.4%). On
comparing age and knowledge scores, a correlation coefficient of 0.288
indicated that with increasing age, knowledge about mental illness will
also increase. Medical officers had the least mean knowledge score
(39.687.56). Postgraduate trainees (47.116.83) scored slightly higher
than junior consultants (44.208.18). Senior consultants had the highest
knowledge score (48.327.46). No gender differences were noticed .
Married participants had better knowledge scores when compared to
unmarried participants.
Correlation between knowledge and attitude scores

X axis Knowledge scores, Y axis Attitude scores

A non-parametric Spearmans rank order correlation was performed to
correlate total knowledge and total attitude scores. This revealed a strong
positive relationship between knowledge and attitude among the
participating medical professionals (p<0.05). The Correlation Coefficient of
0.379 indicated that participants with better knowledge scores have
better attitudes towards mental illness.

As of 2005 the world health organization reported that 154 million people
worldwide, suffered from depression. Nearly 106 million people suffer from
alcohol and other substance use disorders52. Upto 25% of the global
population is said to develop one or more mental or behavioral disorders
during their lifetime53. Despite approaching a number of medical officers

and senior specialists and sub specialists, a majority of them did not
return questionnaires. Some medical officers felt that the knowledge
questionnaire was too extensive and lost interest in completing the
questionnaire. Our study revealed overall negative attitudes toward
mental illness (-6.0560 8.883) among MPs. This is in agreement to the
results obtained in other studies also26, 30, 37, and 70. Participants who
were married and those with a higher number of years of experience
displayed better attitudes toward mental illness. This relationship between
age and experience is in accord with earlier studies on attitudes among
physicians38, 35. However there have been other studies with
contradicting results72. The negative attitude among MPs in our study
reflects general societal attitudes about mental illness. Negative attitudes
also exist in regard to the course of illness and the efficacy of the
treatment and associated side effects of medications prescribed. This view
is supported by many Indian and western studies72, 73. The rapid onset
of heroin dependence, associated deterioration in personality, distressing
withdrawal symptoms and rapid deterioration in functioning confers a
predominantly negative tag to heroin use even among those with
adequate knowledge. Physicians generally perceive drug users as violent,
distrustful, and manipulative56, 57. Surprisingly alcohol use received a
more or less neutral score among MPs (0.66 3.7), furthermore there
were no gender differences in the same. The apparent neutral attitude
toward alcohol use is possibly secondary to the nature of the AMIQ
vignette which describes a previously dependent individual who is
currently attending AA (Alcoholics Anonymous) meetings. The legality of

alcohol use tends to soften views in regard to the same. Physicians

generally report positive attitudes towards counseling patients about
unhealthy alcohol use58. However, there have also been studies which
report predominantly negative attitudes in dealing with patients with
alcohol use problems62. Depression was the only mental illness that
received primarily positive scores (3.14 3.31). Most GPs are comfortable
dealing with the needs of depressed patients66. A number of physicians
have a strong sense of responsibility for managing depression67