Attitude of medical students toward mentally ill patients: impact of a clinical psychiatric round :MA Alaa El-Din, Ghada R Amen, Reem H ElGhamry, Dalia A.M. Mahmoud, Hagar H.A.H. Kandel, The Egyptian Journal of Neurology, Psychiatry and Neurosurgery

ORIGINAL ARTICLE
Year : 2016 | Volume : 53 | Issue : 1 | Page : 6--11

Attitude of medical students toward mentally ill patients: impact of a clinical psychiatric round

MA Alaa El-Din, Ghada R Amen, Reem H ElGhamry, Dalia A.M. Mahmoud, Hagar H.A.H. Kandel
Department of Neuropsychiatry, Institute of Psychiatry, Ain Shams University, Cairo, Egypt

Correspondence Address:
Reem H ElGhamry
MD, MRCPsych, Lecturer of Psychiatry, Institute of Psychiatry, Neuropsychiatry Department, Faculty of Medicine, Ain Shams University. 8 Mugamaa El Ferdous, Nasr St., Nasr City, Cairo, 11471
Egypt

Abstract

Background Stereotyped cognitive schemes are the main cause of casting out patients with mental illness. Educational psychiatry programs have to be re-evaluated as medical students often have misconceptions about psychiatry. Objective The aim of the present study was to examine the attitude of fifth-year medical students toward psychiatric patients and disorders, and to reveal the influence of psychiatric study experience on their attitudes. Participants and methods In this interventional study, 300 fifth-year students from Ain Shams University Medical School were enrolled. Sociodemographic data sheet, Fahmy and El Sherbiny«SQ»s Social Classification Scale, and the Mental Illness Clinician Attitude Scale-2 were used on the first and last day of a 3-week clinical psychiatric round. Results Data before and after the round were compared and showed no significant change in Mental Illness Clinician Attitude Scale-2 scores among the studied sample after the psychiatric round. Only 4% of the students chose psychiatry as a future career with neutral attitude and had worse attitude after rotation. Students who had significant positive attitude at the beginning of the round ended up with a significantly more negative attitude, whereas those with significantly negative attitudes improved at the end of the round. Conclusion Three weeks may not be sufficient time to allow students to follow up the patients to notice their improvement as regards treatment and return to their functional baseline. Thus, students perceived mentally ill patients being untreatable. Greater emphasis on doctor-patient relationship and exposure to patients with psychiatric illness, which responds rapidly to treatment and students taking direct patient responsibility, may lead to the production of more favorable attitudes.

How to cite this article:
Alaa El-Din M A, Amen GR, ElGhamry RH, Mahmoud DA, Kandel HH. Attitude of medical students toward mentally ill patients: impact of a clinical psychiatric round.Egypt J Neurol Psychiatry Neurosurg 2016;53:6-11

How to cite this URL:
Alaa El-Din M A, Amen GR, ElGhamry RH, Mahmoud DA, Kandel HH. Attitude of medical students toward mentally ill patients: impact of a clinical psychiatric round. Egypt J Neurol Psychiatry Neurosurg [serial online] 2016 [cited 2023 Dec 7 ];53:6-11
Available from: http://www.ejnpn.eg.net/text.asp?2016/53/1/6/176321

Full Text

Introduction

Psychiatry as a discipline is often perceived as 'different' by other medical professionals as much as by a common man. This perception of 'difference' may give rise to stigma toward both mental illness and mental health professionals. Mental health professionals are thus both recipients of stigma and agents who can de-stigmatize psychiatry [1].

In Egypt, one of the most common reasons for the minuscule usage of available psychiatric services by the lay-public is stigma [2]. Stigma is defined as an amalgamation of three predicaments: lack of sufficient knowledge (ignorance), negative attitudes (prejudice), and exclusion or avoidance behaviors (discrimination) [3]. Patients experience discrimination from the healthcare community, which layers up self-stigma, resulting in fear of, and withdrawal from, seeking treatment and social support [4].

Furthermore, how medical practitioners perceive the mental illness affects their capacity to recognize, appropriately treat, and refer patients who have mental health problems. It is therefore important that training of medical students ensures more understanding attitude toward mentally ill patients [5].

Medical students' view about psychiatry has been evaluated for almost a century, and how attitudes toward mental illness can be positively changed is a topic of widespread interest. However, the methodology and general conditions of various studies were inconsistent [6].

The surveys from the Middle East region, observing medical students' attitudes toward psychiatry, failed to show any significant improvement in their attitude following their training during clerkship [7].

As traditional teaching methods are directed more toward seeding commencing knowledge than toward changing the attitudes of students, out of the box teaching techniques should be used to bring brain-storming and attitudinal changes to develop interest among medical students. Revised programs such as case-based and problem-based learning, small group teaching, simulated patients, using movies, multidisciplinary seminars, integrated teaching, attitude questionnaires, objective structured clinical examinations, etc. could be introduced in the curriculum to achieve this objective [8]. Being a good role model in psychiatric clinical practice is mandatory for a psychiatrist, so as to reduce the associated stigma, especially among other medical professionals [9].

Aim

The aim of the present study was to examine the attitude of fifth-year medical students toward psychiatric patients and psychiatric disorders, and to identify the impact of the psychiatric clinical round on changing the attitude of the students.

Participants and methods

The present interventional study included a sample of 300 fifth-year medical students attending psychiatric rounds at the Institute of Psychiatry, Ain Shams University Hospitals. Before participating in the study, all the students signed an informed consent. An approval of the study protocol was obtained from the ethical committee.

At the beginning and end of the round, the students answered a specially designed sheet recording sociodemographic data and preferred future specialty, upgraded Fahmy and El-Sherbiny's Social Classification Scale [10] to assess the socioeconomic levels, and the Mental Illness Clinician Attitude Scale-2 (MICA-2) medical student version [11], which measures the students' attitude toward psychiatry. MICA-2 was developed by the Health Services and Population Research Department, Institute of Psychiatry, King's College London. It is self-administered and comprised 16-item Likert-type scale (responses ranging from strongly agree to strongly disagree). A high overall score indicates a more negative attitude.

Students were enrolled from four rounds in a 3-month period, each round with a 3-week duration. During the psychiatric round, students were given intensive training on psychiatric disorders (mood, schizophrenia, anxiety, somatoform, stress-related, ADHD, conduct, dementia, delirium, and conversion). In lectures, clinical demonstrations, and case discussions, advanced information about interviewing skills, psychotherapy and pharmacotherapy were given. In addition, a weekly roleplay session was held, where students played the patient, the relative, and the psychiatrist. At the end of the round, a multiple choice exam was set with revision on the previous day.

Statistical analysis

The collected data were coded, tabulated, and statistically analyzed using the statistical package for the social sciences (SPSS, version 18.0) [12]. Qualitative variables were described as number and percentages. Quantitative variables were described as mean and SD. The χ2 -test was used to detect presence or absence of significant association between two categorical variables. The independent sample t-test was used to compare between means of different groups. The paired t-test was used to compare between means of the same group before and after the round. Analysis of variance tests were used when comparing quantitative data between more than two groups. P value used to indicate the level of significance (P < 0.05 was considered significant, P < 0.01 was considered highly significant).

Results

The research sample included 191 (63.7%) women and 109 (36.3%) men. Their ages ranged from 20 to 24 years, with a mean age of 21.3 ± 0.6 years. There were 258 (86%) Muslim and 42 (14%) Christians, whereas 259 students were single and only five students were married. As regards the social class, 209 (69.7%) students were of high social class, 84 (28%) of middle social class, and only seven students were of low social class. Most of the students had no family history of mental illness (249, 83%), 44 (14.7%) had a second-degree and third-degree relatives with mental illness, and 17 (5.7%) had a first-degree relative with mental illness. When asked about their preferred future specialty, the majority of the students specified medical (105, 35%) and surgical (77, 25.7%) fields as their specialty, only 14 (4.7%) students chose psychiatry, and 104 (34.7%) students did not specify any specialty.

On exploring the students' attitude before the psychiatric round, results showed that the mean MICA-2 score of the students was 50.7 ± 7.8 with a range of 30-72. After analysis of the results, students who scored 1 SD or less below the mean of the group (MICA-2ͳ43) were considered to have positive attitude toward mental illness, those who scored 1 SD or more above the mean of the group (MICA-2΃59) were considered to have negative attitude, and those who scored from 43 to 59 were considered to have neutral attitude.

Trying to detect which parameter could have affected the students' attitude, we compared the MICA-2 scores of students with different studied parameters. Results showed that single students significantly (P = 0.014) had better attitude (MICA-2: 50.6 ± 7.9) than did married students (MICA-2: 52.2 ± 0.8), and that students who chose psychiatry as their preferred specialty had significantly (P = 0.008) better attitude (MICA-2: 44.8 ± 10.1) than did others [Table 1]. Those who had a relative with mental illness had better attitude (MICA-2: 48.8 ± 8.9) than those who did not, which was approaching significance (P = 0.070). Otherwise, there were no significant differences between students with different sex, religion, and socioeconomic status.{Table 1}

A comparison between students with negative attitude (N = 51) and those with positive attitude (N = 45) before the start of the round showed that only family history of mental illness significantly differentiated between them [Table 2].{Table 2}

To detect the impact of the clinical psychiatric round on students' attitude, mean MICA-2 scores of students before the round were compared with those after the round, and no statistically significant change in MICA-2 score of the studied sample after psychiatric round were found, with a mean of 50.7 ± 7.8 and a range of 31-74. On Comparing MICA-2 scores of students before and after the round, results showed that students with positive attitudes before the psychiatric round (n = 51) showed a significant increase in MICA-2 scores toward the neutral attitude range (39.1 ± 3.6-52.9 ± 7.7, P < 0.001) after the round, and students with negative attitudes (n = 45) showed a significant decrease in MICA-2 scores falling in the neutral attitude range as well (62.7 ± 4.7-49.6 ± 8.6, P < 0.001) [Table 3].{Table 3}

To detect which groups of students were affected by the psychiatric round, we compared the MICA-2 scores of students with different studied parameters. The following was detected: married students had a significant decrease in MICA-2 score (P = 0.041), hence better attitude, and had significantly better attitude than did single students [Table 1]. Students who chose psychiatry as a specialty had a significant increase in MICA-2 score (P = 0.035), which means worse attitude, and students with nonspecified preferred specialty turned to have significantly the lowest MICA-2 scores (P = 0.011) among others after the round [Table 1]. Moreover, students who had positive family history of mental illness experienced an increase in MICA-2 score - in other words, worse attitude.

Discussion

During the past decades numerous studies have found out strongly negative public attitudes toward the mentally ill. This raises an important question: how public opinion might be influenced? This could be achieved through key community leaders, those who are highly respected in the society and doctors belonging to this group of people. This is one of the reasons why medical students, as future key community leaders, were studied in the present study as regards their attitudes toward the mentally ill [13].

In our study, there was no significant change in the mean MICA-2 score among the studied sample after psychiatric round. Unexpectedly, students who reported positive attitudes toward psychiatry on the first day of the rotation had a significant decline in their attitude toward the neutral attitude range after the rotation, whereas students with negative attitudes showed a significant inclination toward the neutral attitude range after the rotation. Negative attitude toward psychiatry or the psychiatrist's role has frequently been observed by a number of authors in different countries [14-17]. Furthermore, it is accepted that there are considerable difficulties in attempting to modify these negative attitudes during the processes of medical training [15],[18],[19].

This might be explained by students' lack of interest in learning more about psychiatry, unfortunately due to the trending notion that psychiatry is not an important field in practice besides all other branches of internal medicine and pediatrics piled up in that medical year curriculum. Another factor is that though the rotation was technically 3-week long, during the first week the students spent much time on their own to overcome their fear of the patients, rather than actually seeing patients, and during the last week students were more focused on the end-of-rotation exams than they were on following the progress of their individual patients. In addition, topics were presented for merely a couple of hours each with teaching techniques not efficient to correct the stigma that patients are just complicated dangerous persons not viewed holistically.

In agreement with this explanation, a study by Ortiz et al. [6] found out that students cutting through a 3-week rotation snapshot were not able to perceive the complexities of the treatment of mental disorders and were left with their original fixed misconceptions.

In contrast, a recent study in India suggested that students who had undergone psychiatry course held positive attitudes toward people with mental illness, with an improvement in benevolent and stigmatization domains [20]. Whereas a significant decrease in negative and stigmatizing views toward mental illness was concluded by other studies after exposure to psychiatry practice [21],[22],[23].

Nevertheless, significant improvement in students' attitudes displayed at the end of rotation which had a minimum duration of six weeks. Moreover, no sufficient results noticed, when applied in attendance duration less than 6 weeks [24],[25],[26]. Therefore, the 3-week duration provided in rotations in this research work was not enough to acquire sufficient knowledge or clinical skills.

Other factors that led to a positive attitudinal change during a clinical psychiatric rotation were that students were professionally taking direct patient responsibility, emphasizing on the doctor-patient relationship, and seeing patients who responded rapidly to treatment [27]. In addition, other studies suggested that the attitude toward mental illness and patients improved following an accountable adherence to clinical settings in psychiatry [28],[29].

Another interesting finding of the research is that only 4.7% of students chose psychiatry as a future career, compared with 35 and 25.7% who chose internal medicine and surgery, respectively.

In agreement with these were the results of a study conducted by Wang et al. [30], which studied the five explanatory factors rated by undergraduates for choosing a specialty as a vocation, including the ability to help patients, interesting and challenging work, lifestyle factors, financial reward, and prestige; this shaded negative perceptions of psychiatry in regard to all factors, especially the financial reward and prestige.

Moreover, a study by Muga and Hagali [31] concluded that the choice of psychiatry as a career came after surgery, emergency medicine, pediatrics, internal medicine, obstetrics/gynecology, and anesthesia. The majority of the final-year medical students did not want to become psychiatrists in future because of cultural and personal misconceptions, which they brought with them before the rotation and which, unfortunately, they carried away unchanged at the end. In addition, students lack faith in the efficacy of modern medicine in treating mental illness and the short 3-week rotation does not give them adequate exposure to psychiatry.

In contrast, studies showed that about 22% of the students expressed definite interest in taking up a career in psychiatry with significantly better attitude to psychiatry at the end of the rotation compared with the ones who did not choose psychiatry [23]. The number of students 'definitely considering' psychiatry as a career increased significantly from 4.6 to 10.5% of the students from baseline to follow-up [21].

In addition, positive response to choose psychiatry as a career was seen in a study conducted by Amini et al. [32], a study in which 13.3% of the fourth year and 18.3% of the fifth year medical students considered psychiatry as a strong possibility but claimed that they were more interested in humanities and playing a musical instrument.

The current study reported that students' socioeconomic status had no significant effect on students' attitude before and after the psychiatric round, which might be because of the shared prejudiced cultural schemes, as well as old media messages. These messages have an ingrained negative influence on the way psychiatry is viewed socially, causing apprehensive guarding against patients with the stigma, harassing both the patients and the psychiatry team.

In contrast to these findings, a study exploring notion remarks of medical students when facing patients in mental health institutions found out that iconic positive attitudes toward psychiatry were significantly associated with middle socioeconomic level affiliation [33].

It is known that individuals with a history of mental illness in their families may sometimes be more authoritarian toward psychiatric patients and illnesses than may those without such a history [32]. In contrast, the current study showed no significant differences when students with positive family history of mental illness and those without, yet they still showed better attitude. Similarly, there were significant brighter attitudes shown by the final-year medical students at the University of Papua New Guinea who had a positive family history of mental illness than those who did not [31]. This is could be explained by increased tolerance, higher empathy, and better understanding of how to handle psychiatric patients because of past experiences with a close member.

Another variable studied was marriage and its relation to stigma of mental illness. Obviously, it seemed that no research focused on that point. The current study found that married students significantly had higher MICA-2 scoring before clinical psychiatric rotation and lower MICA-2 after clinical psychiatric rotation, indicating that marriage has a good impact on changing attitude of medical students toward mentally ill patients. However, this finding should be interpreted cautiously as only 1.7% of the students were married. Further research is needed in this area.

The relationship between sex and the attitude toward psychiatry in different studies have reached different conclusions. In the current study, MICA-2 elevation change after psychiatric round was significantly higher in males than in females, and this finding would suggest that the empathy decreased after a clinical psychiatric rotation. A possible explanation of this may be that females perceived psychiatric patients as dangerous, and dangerousness is a key component of attitudinal and behavioral responses toward those with mental health difficulties. Dangerousness, a key stereotype applied to people with mental health difficulties, is associated with a desire for social distance and, according to the public discrimination model, danger appraisals affect behavior because of an increase in fear without a mediating attribution [34].

These findings oppose those of a study by Al-Ansari and Al-Sadadi [7], and by Angermeyer and Matschinger [35]; in these studies, female medical students had a more positive attitude to psychiatry at the end of the clinical rotation. This may suggest that female medical students could have greater empathy toward people with emotional problems. In addition, in these studies, females expressed higher levels of fear and sympathy and lower levels of anger compared with males.

However, in a recent systematic review of population-based studies, a study by Holzinger et al. [36] concluded that women do not seem to display more positive attitudes than do men toward people with mental illness, with a few exceptions. Women are more likely to approve psychosocial approach to mental illness than are men. In addition, it seems that women are more ready to suggest professional help than are men. In line with this finding, a study by Al-Adawi et al. [37] found no association between medical students' attitudes toward mental illness and sex .

Conclusion

It may be concluded that exposure to psychiatric clinical rotation could influence medical students' opinion about psychiatry positively, or negatively, or have no change at all. Three weeks may not be sufficient time to allow students to follow up the patients to notice their improvement as regards treatment and return to their functional baseline. Therefore, students perceived mentally ill patients as being untreatable.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1	Kalra G. Talking about stigma towards mental health professionals with psychiatry trainees: a movie club approach. Asian J Psychiatr 2012; 5 :266-268.
2	Coker EM. Selfhood and social distance: toward a cultural understanding of psychiatric stigma in Egypt. Soc Sci Med 2005; 61 :920-930.
3	Ogunsemi O, Odusan O, Olatawura M. Stigmatizing attitude of medical students towards a psychiatry label. Ann Gen Psychiatry 2008; 25 :7-15.
4	Abd-Malik C, Kannusamy P, Klainin-Yobas P. The effectiveness of mental health-related theoretical education and clinical placement in mental health settings in changing the attitudes of health care students towards mental illness: a systematic review. JBI Database Syst Rev Implement Rep 2012; 10 :14-16.
5	Elafros MA, Mulenga J, Mbewe E, Haworth A, Chomba E, Atadzhanov M, Birbeck GL. Peer support groups as an intervention to decrease epilepsy-associated stigma. Epilepsy Behav 2013; 27 :188-192.
6	Ortiz O, Sánchez-Mora N, Márquez L. Medical students′ attitudes towards mental disorders and their correlation with academic performance. Méd UIS 2010; 23 :199-205.
7	Al-Ansari A, Al-Sadadi A. Attitude of Arabian Gulf University medical students towards psychiatry. Educ Health (Abingdon) 2002; 15 :180-188.
8	Nayak A. Changing medical students′ attitudes to psychiatry through newer teaching techniques. Mens Sana Monogr 2015; 13 :180-186.
9	Wiguna T, Yap KS, Tan BW, Siew T, Danaway J. Factors related to choosing psychiatry as a future medical career among medical students at the Faculty of Medicine of the University of Indonesia. East Asian Arch Psychiatry 2012; 22 :57-61.
10	Fahmy S, El-Sherbini AF. Determining simple parameters for social classifications for health research. Bull High Inst Public Health 1983; 13 :95-108.
11	Kassam A, Glozier N, Leese M, Henderson C, Thornicroft G. Development and responsiveness of a scale to measure clinicians′ attitudes to people with mental illness (medical student version). Acta Psychiatr Scand 2010; 122 :153-161.
12	SPSS. PASW statistics for Windows, version 18.0. Chicago, IL: SPSS Inc.; 2009.
13	Konwar R, Pardal PK, Prakash J, Rythem. Does psychiatry rotation in undergraduate curriculum bring about a change in the attitude of medical student toward concept and practice of psychiatry: a comparative analysis. Ind Psychiatry J 2012; 21 :144-147.
14	Balon R, Franchini G, Freeman P, Hassenfeld IN, Keshavan, MS, Yoder E. Medical students′ attitudes and views of psychiatry: 15 years later. Acad Psychiatry 1999; 23 :30-36.
15	Calvert SH, Sharpe M, Power M, Lawrie SM. Does undergraduate education have an effect on Edinburgh medical students′ attitudes to psychiatry and psychiatric patients?. J Nerv Ment Dis 1999; 187 :757-761.
16	Pailhez G, Bulbena A, Bulbena-Cabre A. Changes in the attitudes, opinions, and vocational tendencies towards psychiatry among students during medical degree. Arch Psiquiat 2008; 2 :96-108.
17	Gulati P, Das S, Chavan BS. Impact of psychiatry training on attitude of medical students toward mental illness and psychiatry. Indian J Psychiatry 2014; 56 :271-277.
18	Pan PC, Lee PW, Lieh-Mak FF. Psychiatry as compared to other career choices: a survey of medical students in Hong Kong. Med Educ 1990; 24 :251-257.
19	Galletly CA, Schrader GD, Chesterman HM, Tsourtos G. Medical student attitudes to psychiatry: lack of effect of psychiatric hospital experience. Med Educ 1995; 29 :449-451.
20	Poreddi V, Thimmaiah R, Math SB. Attitudes toward people with mental illness among medical students. J Neurosci Rural Pract 2015; 6 :349-354.
21	Lyons Z, Janca A. Impact of a psychiatry clerkship on stigma, attitudes towards psychiatry, and psychiatry as a career choice. BMC Med Educ 2015; 15 :34.
22	Reddy JP, Tan SM, Azmi MT, Shaharom MH, Rosdinom R, Maniam T, et al. The effect of a clinical posting in psychiatry on the attitudes of medical students towards psychiatry and mental illness in a Malaysian medical school. Ann Acad Med Singapore 2005; 34 :505-510.
23	Adebowale TO, Adelufosi AO, Ogunwale A, Abayomi O, Ojo TM. The impact of a psychiatry clinical rotation on the attitude of Nigerian medical students to psychiatry. Afr J Psychiatry (Johannesbg) 2012; 15 :185-188.
24	Ghadirian A, Engelsmann F. Medical student′s attitude to psychiatry: a ten year comparison. Med Edu 1982; 16 :39-43.
25	Wilkinson DG, Toone BK, Greer S. Medical students′ attitudes to psychiatry at the end of the clinical curriculum. Psychol Med 1983; 13 :655-658.
26	Araya RI, Jadresic E, Wilkinson G. Medical students′ attitudes to psychiatry in Chile. Med Educ 1992; 26 :153-156.
27	Shen Y, Dong H, Fan X, Zhang Z, Li L, Lv H, et al. What can the medical education do for eliminating stigma and discrimination associated with mental illness among future doctors? Effect of clerkship training on Chinese students′ attitudes. Int J Psychiatry Med 2014; 47 :241-254.
28	Mino Y, Yasuda N, Kanazawa S, Inoue S. Effects of medical education on attitudes towards mental illness among medical students: a five-year follow-up study. Acta Med Okayama 2000; 54 :127-132.
29	De-Alwis A, Perera R, Vasantha H, Fernando S. The attitude of medical students towards the mental mentally ill: the impact of a clinical attachment in psychiatry. Sri Lanka J Psychiatry 2012; 3 :12-15.
30	Wang X, Xiang X, Hao W, Liu T. Attitudes toward psychiatry as a prospective career among medical students in their pre-clinical year in China - a pilot study. PLoS One 2013; 8 :e73395.
31	Muga F, Hagali M. What do final year medical students at the University of Papua New Guinea think of psychiatry? PNG Med J 2006; 49 :126-136.
32	Amini H, Majdzadeh R, Eftekhar-Ardebili H, Shabani A, Davari-Ashtiani R. How mental illness is perceived by Iranian medical students: a preliminary study. Clin Pract Epidemiol Ment Health 2013; 9 :62-68.
33	Giasuddin NA, Levav I, Gal G. Mental health stigma and attitudes to psychiatry among Bangladeshi medical students. Int J Soc Psychiatry 2015; 61 :137-147.
34	Aker S, Aker AA, Boke O, Dundar C, Sahin AR, Peksen Y. The attitude of medical students to psychiatric patients and their disorders and the influence of psychiatric study placements in bringing about changes in attitude. Isr J Psychiatry Relat Sci 2007; 44 :204-212.
35	Angermeyer MC, Matschinger H. Public beliefs about schizophrenia and depression: similarities and differences. Soc Psychiatry Psychiatr Epidemiol 2003; 38 :526-534.
36	Holzinger A, Floris F, Schomerus G, Carta MG, Angermeyer MC. Gender differences in public beliefs and attitudes about mental disorder in western countries: a systematic review of population studies. Epidemiol Psychiatr Sci 2012; 21 :73-85.
37	Al-Adawi S, Dorvlo AS, Al-Ismaily SS, Al-Ghafry DA, Al-Noobi BZ, Al-Salmi A, et al. Perception of and attitude towards mental illness in Oman. Int J Soc Psychiatry 2002; 4:305-317.