Original Article

Medical Student Attitudes About Mental Illness: Does Medical-School Education Reduce Stigma?
Ania Korszun, Ph.D., M.D., FRCPsych, Sokratis Dinos, B.Sc., M.Sc., Ph.D. Kamran Ahmed, MBBS, B.Sc., MRCPsych, Kamaldeep Bhui, M.D., FRCPsych
Background: Reducing stigma associated with mental illness is an important aim of medical education, yet evidence indicates that medical students attitudes toward patients with mental health problems deteriorate as they progress through medical school. Objectives: Authors examined medical students attitudes to mental illness, as compared with attitudes toward other medical illness, and the inuence of the number of years spent in medical school, as well as of several key socio-demographic, ethnic, and cultural variables. Methods: A group of 760 U.K. medical students completed a nationwide on-line survey examining their attitudes toward patients with ve conditions (pneumonia, depression, psychotic symptoms, intravenous drug use, long-standing unexplained abdominal complaints), using the Medical Condition Regard Scale (MCRS). Students were also asked whether they had completed the psychiatry rotation or had personal experience of mental disorders themselves or among their friends or family members. They were also asked about their ethnic group (using U.K. national census categories), religious afliation, and how important religion was in their lives. Independent-samples t-tests and one-way ANOVA were used to compare differences between groups on the MCRS. Results: Students showed the highest regard for patients with pneumonia and lowest regard for patients with long-standing, unexplained abdominal complaints. Although attitudes toward pneumonia were more positive in fth-year students than in rstyear students, attitudes toward unexplained chronic abdominal pain were worse in fth-year students than in rst-year students. Personal experience of mental health treatment, or that among family and friends, were associated with less stigmatizing attitudes. Men showed more stigmatization than women for nearly all conditions; Chinese and South Asian students showed more
Received November 16, 2010; revised May 24, August 9, September 2, 2011; accepted September 6, 2011. From the Centre for Psychiatry, Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine. Send correspondence to Dr. Korszun; e-mail: a.korszun@ qmul.ac.uk Copyright 2012 Academic Psychiatry

stigmatizing attitudes toward delusions and hallucinations than their white British counterparts. Conclusions: Medical students in this survey showed the lowest regard for patients with unexplained abdominal pain, and these attitudes were worse in the most experienced medical students. Students gender, culture and direct or indirect experience of mental illness inuenced stigmatizing attitudes.
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he stigma associated with mental illness causes feelings of shame and social isolation and prevents people from getting help (1, 2). Stigmatization uses negative labels and stereotypes and arises from ignorance and prejudicial attitudes that lead to discriminatory behavior (3). The general public continues to hold negative attitudes toward mental illness despite various national campaigns for reducing stigma (4, 5). But are attitudes of health professionals and medical students any different? Studies have shown that even psychiatrists share the publics stereotypes about the dangerousness of people with mental illness and only hold a more favorable view than lay people if they themselves have personal or family experience of mental illness (6). In a recent survey of U.K. psychiatrists (clinicians and academics), 40% of respondents perceived their own profession as being stigmatized, particularly by colleagues from other specialties (7). If medical educators are to reduce stigmatization of mental illness and psychiatric treatments, the fundamental causes of stigma need to be addressed to ensure that the next generation of doctors does not develop these negative attitudes. Medical students attitudes are greatly inuenced by their experiences at medical school, not only during their psychiatry placements, but also in their interaction with all other clinicians in various disciplines. Therefore, the whole culture at a medical school plays an important role. It is thus particularly disturbing that reports show that students
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attitudes appear actually to worsen as they progress through medical school; for example, senior students are more likely to use pejorative terms for people with mental disorders and feel less able to disclose their own mental illness than more-junior medical students (8) (9). Although there are some reports of students attitudes to mental disorders improving after psychiatry placements (10), particularly through gaining an understanding of the causation of psychiatric disorders (11), others have shown no improvement (12, 13) or only a transient effect. Psychiatric disorders are common, so all medical students, regardless of the specialty they choose, will go on to treat people with mental illness. Tackling stigma in medical schools is therefore an important way of addressing stigma in later practice. We need to understand medical students attitudes to mental disorders in order to develop effective learning resources that specically address the consequences of stigmatizing attitudes and practices. Attitudes to mental illness also vary across cultural and ethnic groups (14), and there is a wide ethnic and cultural diversity within the U.K. population, and, increasingly, in the medical student population. This factor needs to be taken into account in medical school curricula, although the same applies to training of all health professionals (15). We conducted a nationwide survey of medical students to examine their attitudes toward mental disorders, versus medical disorders, and how these varied according to number of years in medical school, as well as according to a number of key socio-demographic, ethnic, cultural, and religious variables. Methods The questionnaire comprised a series of sociodemographic questions on age, gender, medical school year (and whether students were graduates at entry). In the U.K., the majority of students enter medical school at age 18 or 19, after nishing high school, and complete a 5-year undergraduate program. There is also a newer, 3-year, graduate-entry course for students with a non-medical rst degree (more similar to the situation in other countries, including the United States). Students were also asked about future career preferences and whether they had completed the psychiatry rotation. The way in which psychiatry is taught differs across medical schools in the U.K., although, at most schools, the main clinical attachment is about 6 weeks long and occurs during the 3rd or 4th year of a 5-year course. The course content is generally similar throughout the U.K., but the degree to which mental health is integrated throughout the whole medical curriculum varies (16).
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The questionnaire also included questions on whether students had past experience of mental health problems themselves or in their friends or family members. They were asked about their ethnic group (using U.K. national census categories), religious afliation, and how important religion was in their lives. The questionnaire examined students attitudes toward patients with ve medical conditions (intravenous [IV] drug use; long-standing unexplained abdominal complaints (UAC); long-standing auditory hallucinations and paranoid delusions; pneumococcal pneumonia; depression and intermittent suicidal thoughtspresented in this order) using a validated psychometric instrument, the Medical Condition Regard Scale, (MCRS) (17). All participants were asked about their attitudes toward all ve cases, using the MCRS, which consists of 11 questionnaire items (Figure 1) that use a 6-point Likert scale, ranging from Strongly Disagree (rated as 1) to Strongly Agree (rated as 6). The minimum score that can therefore be obtained is 11, and the maximum, 66. A score of 11 would signify the lowest possible regard for that medical condition. A higher score therefore signies a higher level of regard for the medical condition and a more positive attitude toward the illness. Six items of the scale are positively worded and ve items are negatively worded, to prevent response bias. Independent-sample t-tests and one-way ANOVAs were used to compare differences among groups on the MCRS on the basis of demographic (gender, ethnicity, and religious background), educational (medical year, completion of psychiatry rotation), and mental health (experience of mental illness personally and through friends/relatives) characteristics. ANOVAs (for overall effect sizes) were performed, using Bonferroni pairwise comparisons, to reveal those characteristics that showed statistically signicant differences. Ethics approval for the study was obtained from Queen Mary Research Ethics Committee (QMREC2007/78, amendment 13/9/09). An online questionnaire was used. The link to the questionnaire was distributed through the Medical Schools Council (a central educational organization with links to all U.K. medical schools) to medical school ofces throughout the U.K. The questionnaire was completed anonymously on-line (neither students name nor medical school was identied). Results Sample Characteristics A group of 760 students completed the survey. Because of the level of anonymity stipulated by the Ethics Committee, it was not possible to know how many schools were eventually
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KORSZUN ET AL. FIGURE 1. Students Attitudes Toward Patients With Five Medical Conditions

THIS SECTION IS ABOUT YOUR ATTITUDES TOWARD WORKING WITH DIFFERENT TYPES OF PATIENTS Please do not think too much about the statements, and answer them as quickly as you can. Patients who are: IV drug users Long-standing abdominal complaints with no abnormalities found on exam Long-standing auditory hallucinations and paranoid delusions Pneumococcal pneumonia Depression and intermittent suicidal thoughts

!! !
included, as it would depend on the relevant administrator at each school to send out the link to the students. Thus, because it is not known who actually received the web-link, it is not possible to determine the percentage response rate of the group. The mean age of the participants was 23.8 years (range: 17 31 years); 67% (N=509) were women, and 33% (N=251) were men. The majority of the students identied themselves as being White (64.9%; N=459); the remainder, South Asian (19.1%; N=145); Black (2%; N=15); Chinese (5.9%; N=45); mixed (3.3%; N=25); and Other (1.6%, N=12). More than half of the participants stated that they belong to a religious group (57.6%; N=438), comprising a variety of religions (.10). Responses to How important is religion to you? were evenly divided: 43.3%, Important; and 53%, Not Important. There were more non-graduate (73.2%; N=556) than graduate (26.8%; N=204) entry students. The respondents were fairly evenly spread through all medical school years: Year 1: 24%, Year 2: 18%, Year 3: 19%, Year 4: 24%, Year 5: 14%. The majority of the students had not started their psychiatry rotation yet (70%; N=532), whereas 6.7%
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(N=51) were doing it at the time of the study, and 22.9% (N=174) had completed it; 6% stated that they were interested in pursuing a career in psychiatry. A very large percentage of participants (65.5%; N=498) reported that they have experienced friends and/or family having been treated for anxiety or depression or emotional, nervous, or mental health problems. On the other hand, 17.8% (N=135) stated that they have personally been treated for mental health problems. Differences in Attitudes Differences in attitudes on the MCRS measures for UAC, IV drug use, delusions and hallucinations, pneumonia, and depression and suicidal thoughts) were tested in relation to demographic, educational, and mental health experience characteristics. Gender Female medical students had signicantly higher levels of regard for patients with UAC, IV drug use, longstanding delusions and hallucinations, and depression and
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suicidal thoughts than did male students (see Table 1 for t-test and mean scores). Ethnicity Ethnicity had a statistically signicant effect on attitudes toward patients with delusions and hallucinations; pneumonia; and, also, depression and suicidal thoughts. Pairwise comparisons regarding attitudes toward delusions and hallucinations showed that White participants had higher regard for patients with delusions and hallucinations than participants of Chinese and South Asian background (Table 1). Religion No signicant differences were found between participants who stated that they belong to a religious group and participants with no religion. Similarly, no differences were found according to the importance attached to religion (Table 1). Education Year-1 students had the highest level of regard for patients with UAC, and Year-5 students had the lowest (Table 2). Year-1 students had the lowest level of

regard for patients with pneumonia, and Year-5 students had the highest; attitudes improved over the course of medical school from Years 1 to 5. Completion of Psychiatry Rotation Participants who had completed their psychiatry rotation had signicantly lower regard for patients with UAC than students who had not started their rotation (Table 2). On the other hand, students who had completed their psychiatry rotation had signicantly higher regard for patients with pneumonia than students who had not started their rotation. Graduate Entry The t-tests revealed no differences between graduate-entry students and undergraduate-entry students in attitudes toward all the conditions measured (Table 2). Experience of Mental Illness, Personally or Through Friends or Relatives: Personal Experience of Being Treated for Mental Illness Medical students who had personally been treated for a mental disorder, such as anxiety or depression, showed signicantly higher levels of regard

TABLE 1. Demographic Characteristics in Relation to Medical Students Attitudes Toward Different Conditions, mean (N; SD)
MCRS: Unexplained Abdominal Complaints Gender Men Women 42.6 (251; 7.8) 44.6 (509; 7.3) t[758]=3.54; p ,0.001 43.9 (459; 7.4) 43.8 (145; 8.2) 45.1 (15; 6.4) 43.5 (45; 8.3) 46.4 (25; 6.4) 42.8 (12; 6.3) F[5, 695]=0.69; NS

MCRS: IV Drug Use 44.4 (239; 7.3) 45.7 (480; 6.9) t[717]=2.23; p ,0.025 45.5 (437; 7.1) 44.6 (134; 7.1) 46.1 (13; 6.6) 43.7 (42; 7.7) 47.5 (24; 7.8) 45.7 (12; 4.9) F[5,656]=1.26; NS

MCRS: Delusions and Hallucinations 48.3 (234; 7.8) 49.5 (480; 6.9) t[712]=2.1; p ,0.032 49.7 (430; 6.8) 47.5 (135; 8.1) 47 (14; 7.7) 46.1 (44; 8.6) 51.7 (23; 7.1) 50.2 (12; 6.6) F[5, 652]=4.22; p ,0.001 49.5 (277; 6.7) 48.8 (412; 7.6) t[687]=1.33; NS

MCRS: Pneumonia 52.2 (247; 6.4) 52.8 (481; 5.9) t[726]=1.39; NS 53.1 (443; 5.8) 51.4 (138; 7.2) 50.9 (15; 6.4) 52.2 (41; 5.2) 54.7 (25; 5.8) 50 (12; 7.8) F[5, 668]=2.7; p ,0.05 53.1 (287; 6.2) 52.4 (416; 6.1) t[701]=1.4; NS

MCRS: Depression and Suicidal Thoughts 49.2 (245; 8.6) 51.9 (484; 7.6) t[727]=4.3; p ,0.001 51.6 (444; 7.9) 49.7 (137; 8.3) 50.6 (15; 6.8) 48.7 (44; 9.1) 51.3 (25; 7.4) 46.5 (10; 9.2) F[5, 669]=2.4; p ,0.05 51.2 (285; 7.9) 50.8 (421; 8.1) t[704]=0.67; NS

Ethnic background White South Asian Black Chinese Mixed Other

Religious background No religion Belong to religious group

43.5 (295; 7.5) 44.3 (438; 7.6) t[731] = 21.3; NS

45.6 (282; 6.9) 45.1 (412; 7.2) t[692]=1.01; NS

Importance of religion Important Not important

44.1 (329; 7.8) 43.7 (403; 7.4) t[730]=0.78; NS

45.5 (310; 6.8) 45.1 (384; 7.2) t[692]=0.61; NS

49.1 (307; 7.3) 49.1 (381; 7.4) t[686]=0.087; NS

52.5 (315; 6.3) 52.8 (387; 5.9) t[700] = 20.63; NS

51 (315; 8.1) 50.9 (390; 8.03) t[703]=0.22; NS

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KORSZUN ET AL. TABLE 2. Educational Characteristics in Relation to Medical Students Attitudes Toward Various Conditions, mean (N; SD)
MCRS: Unexplained Abdominal Complaints Medical Year First Second Third Fourth Fifth 45.3 (181; 8.18) 44.8 (123; 6.38) 45.2 (150; 6.68) 42.8 (192; 7.3) 41.2 (114; 8.1) F[4, 755]=8.265; p ,0.001 43.8 (556; 7.4) 44.3 (204; 7.8) t[758] = 20.805; NS 44.6 (532; 7.2) 43.4 (51; 6.8) 42 (174; 8.3) F[2, 754]=8.1; p ,0.001

MCRS: IV Drug Use 44.6 (173; 7.4) 45.2 (114; 5.9) 46.4 (138; 7.2) 44.9 (185; 7.1) 45.7 (109; 7.1) F[4, 714]=1.47; NS 45 (523; 6.9) 46 (196; 7.2) t[717] = 21.67; p=0.094 45.2 (500; 7.1) 45.3 (46; 6.8) 45.6 (170; 7.2) F[2, 713]=0.22; NS

MCRS: Delusions and Hallucinations 49.3 (172; 7.3) 48.8 (113; 6.6) 49.3 (138; 7.3) 48.8 (184; 7.4) 49.3 (107; 7.7) F[4, 709]=0.191; NS 48.9 (519; 7.4) 49.6 (195; 6.7) t[712] = 21.13; NS 48.9 (499; 6.9) 49.6 (48; 7.3) 49.5 (166; 8.2) F[2, 710]=0.520; NS

MCRS: Pneumonia 51.1 (170; 6.5) 52.6 (119; 6.5) 52.9 (142; 6.1) 53.2 (185; 5.6) 53.5 (112; 5.7) F[4, 723]=3.79; p ,0.005 52.4 (534; 6.2) 53.3 (194; 5.8) t[726] = 21.88; p=0.061 52.3 (508; 6.2) 51.4 (49; 6.3) 53.9 (170; 5.5) F[2, 724]=5.33: p ,0.005

MCRS: Depression and Suicidal Thoughts 50.9 (178; 8.3) 52.4 (119; 7.3) 51.3 (141; 8.3) 49.9 (179; 8.1) 50.8 (112; 8.1) F[4, 724]=1.75; NS 50.8 (533; 8.3) 51.6 (196; 7.4) t[727] = 21.17; NS 51.1 (513; 7.9) 50.3 (50; 8.3) 50.7 (165; 8.3) F[2, 725]=0.351; NS

Graduate No Yes

Psychiatry rotation Not started Currently doing it Completed

for patients with depression, hallucinations, and delusions and UAC than students who had no such personal experience (Table 3). Having Family or Friends With a History of Being Treated for Mental Illness Medical students who had a friend or family member who had been treated for mental illness had signicantly higher levels of regard for patients

with depression, pneumonia, longstanding hallucinations and delusions and IV drug use, as compared with students who did not know a friend or family member who had been treated for a mental illness (Table 3). Independent Effects of Demographic and Educational Characteristics Regression analyses were also performed on those demographic and educational characteristics that

TABLE 3. History of Mental Illness in Relation to Medical Students Attitudes Toward Various Conditions, mean (N; SD)
MCRS: Unexplained Abdominal Complaints Personal experience of treatment for mental illness No Yes

MCRS: IV Drug Use

MCRS: Delusions and Hallucinations

MCRS: Pneumonia

MCRS: Depression and Suicidal Thoughts

43.9 (618; 7.4) 44.1 (135; 8.2) t[712] = 22.95; NS

44.9 (585; 7.1) 46.9 (129; 7.1) t[751] = 20.249; p ,0.005

48.7 (583; 7.3) 50.9 (125; 7.3) t[706] = 23.14; p ,0.001

52.6 (594; 6.1) 52.9 (128; 6.3) t[720] = 20.53; NS

50.2 (596; 7.9) 54.4 (128; 7.7) t[722] = 25.49; p ,0.001

Friends/relatives treated for mental illness No Yes

43.8 (254; 7.4) 44.1 (498; 7.6) t[750] = 20.43; NS

43.8 (242; 6.9) 46 (471; 7.1) t[711] = 23.96; p ,0.001

47.1 (240; 7.3) 50.1 (467; 7.1) t[705] = 25.4; p ,0.001

51.7 (247; 6.7) 53.1 (474; 5.7) t[719] = 22.96; p ,0.005

48.9 (250; 7.9) 51.9 (473; 7.9) t[721] = 24.83; p ,0.001

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showed signicant effects in relation to attitude scores (i.e., gender, ethnicity, medical year, graduate-entry status, and psychiatry rotation). This analysis was carried out in order to test independent effects of demographic and educational variables when all variables were entered in the regression models. Separate models were run for each attitude score (dependent variables). Results followed a similar pattern to those reported from ANOVAs and t-tests (see Table 4). In particular, R for regression was signicant for UAC, pneumonia, and depression. Gender was a signicant predictor of all attitude scores (even when R was nonsignicant). Medical school year was a signicant predictor of UAC, pneumonia, and depression; and ethnicity was a signicant predictor of depression when controlling for all other variables. Discussion This study reports the attitudes of a large group of U.K. medical students to mental and other medical illness, by use of the MCRS scale, which has been previously validated and used in a smaller group of U.S. students (17). U.K. study participants were evenly distributed across medical school years and between high school- versus graduateentry students, but with a higher representation of women students. Similar to the U.S. study, the highest regard was shown for patients with pneumonia, with lower scores for mental disorders and IV drug use. Although the scores for all disorders except pneumonia, were higher in U.K. students, it was striking that, in both groups, patients with UAC elicited the lowest regard. There has been a long history of stigmatization of people who have illnesses for which there is no obvious cause and which are deemed to be all in the mind. Our increased understanding of the etiology of psychiatric disorders has contributed to de-stigmatization as well for conditions previously

considered to be psychiatric, such as hypothyroidism, multiple sclerosis, and Huntingtons disease; whereas patients with UAC continue to be stigmatized. However, the whole area of medically unexplained symptoms is under review (18), and, as the underlying causes of previously unexplained conditions, such as irritable bowel syndrome, become identied (19), the stigma associated with them will also be reduced. In the meantime, patients with these distressing conditions continue to be stigmatized, and it is interesting that students have a higher regard for IV drug users than for this group of patients. More concerning is that, whereas students attitudes toward people with pneumonia become even more positive over the years, there is no change in attitudes to depression, psychosis, or drug use. This would imply that we are making little impact at medical school in improving attitudes toward mental disorders. But, most disturbing, is the nding that attitudes toward patients with UAC is clearly worse in senior than in junior students. It is most likely that they have learned these attitudes from their clinical teachers and rolemodels. Students hear pejorative terms, such as crocks (U.S.) and heart-sinks (U.K.), to describe patients who have problems that cannot be readily addressed. Singling out any patient groups as being less worthy of medical attention needs to be challenged in medical school culture, with psychiatry leading the way. Alternatively, students might be frustrated by illness that they cannot control or treat using a more conventional biomedical model. Such experience might undermine condence, and knowledge about management approaches to unexplained medical complaints may not be taught sufciently thoroughly and may explain why attitudes toward pneumonia were generally favorable. It is possible that in those with more stigmatizing attitudes, this may reect their particular clinical experiences; however, in

TABLE 4. Regression Analyses on Demographic and Educational Characteristics and Attitudes Toward Various Conditions
MCRS: Unexplained Abdominal Complaints Gender Ethnic background Medical year Psychiatry rotation Graduate 2.49 (,0.001) 0.823 (NS) 1.02 (,0.001) 20.131 (NS) 0.819 (NS) F[5, 692]=8.9; Adj. R2=0.54; p ,0.001

MCRS: IV Drug Use

MCRS: Delusions and Hallucinations

MCRS: Pneumonia

MCRS: Depression and Suicidal Thoughts 3.12 (,0.001) 20.574 (,0.05) 20.482 (NS) 0.503 (NS) 1.02 (NS) F[5, 692]=6.8; Adj R2=0.40; p ,0.001

Unstandardized Betas (p) 1.55 (,0.01) 1.32 (,0.05) 20.971 (,0.05) 20.040 (NS) 20.333 (NS) 20.161 9 (NS) 0.163 (NS) 20.289 (NS) 0.462 (,0.05) 0.045 (NS) 0.739 (NS) 0.387 (NS) 0.664 (NS) 0.569 (NS) 0.720 (NS) F[5, 678]=1.9; Adj. F[5, 673]=2.1; Adj F[5, 691]=3.69; Adj R2=0.07; NS R2=0.08; p=0.069 R2=0.19; p ,0.005

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this anonymized study, further analysis of this relationship was not possible. Interestingly, women showed a greater regard for all categories of patients except those with pneumonia. This reects the general nding that women are better informed about mental illness and more tolerant toward people with mental disorders (20). Another moderator of attitude was personal experience, or having friends or family members with mental illness, and these respondents had signicantly higher levels of regard for depression, psychosis, and IV drug use. This is consistent with other studies showing that exposure to individuals with mental disorders was associated with more positive attitudes toward medical students with mental illness (21). However, this did not inuence attitudes toward UAC, and it is clear that medical students need to gain an increased understanding of unexplained medical symptoms. Graduate students showed a similar pattern of attitudes toward patients with UAC. Graduate-entry students are generally considered to be more self-directing, challenging, and questioning (22) and are reported to perform better academically (23). However, they appear to be as susceptible as school-entry students to the strong inuence of medical school culture on attitudes toward patients with unexplained medical symptoms or mental disorders. Interestingly, despite the diversity of religions represented in this study and the even distribution between people who nd religion important versus unimportant in their lives, there was no effect on attitudes. This may be because the study was underpowered, but it could also reect the way that attitudes acquired at medical school override cultural differences. Other limitations of the study were that, because responses were anonymous, it is not known how many U.K. medical schools were represented and, thus, how many students were potentially able to participate. However, the characteristics of our sample were comparable to those of the U.K. medical student population (24), which comprises 60% women, 70% white ethnicity, and a mean age on admission of 19.2 years and 25.5 years for undergraduate-graduate entry, respectively. Also, the MCRS is a self-report scale of attitudes to hypothetical patients, rather than a true representation of students responses in real clinical situations. The nding, however, that attitudes to psychosis differ by culture is interesting. White medical students had higher levels of regard than Chinese and South Asian medical students for patients with long-standing delusions and hallucinations. Chinese students had the lowest level of regard for these patients. Research has identied particular cultural values that are deeply held by people from Chinese societies, such as the importance of preserving face, as
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contributing to stigmatizing attitudes to mental disorders (25, 26). Cultural models of illness tend to be applied alongside bio-medical models in East and South Asian cultures (27, 28). For example, some Indian medical schools teach Ayurvedic medicine alongside western biomedicine, and traditional Chinese Medicine is used alongside Western biomedicine in China; but these culturally-inuenced illness models may also carry stigmatizing attitudes about mental illnesses that are not helped by these traditional systems of healthcare. Understanding pluralistic illness models becomes increasingly important when patients and doctors are from different cultures. We have diverse patient and medical student populations, and it is clear that we need to take culture into account. However, as yet, there is little curricular time devoted to this, although there is evidence that additional teaching on cultural psychiatry can inuence students treatment of patients (29). Conclusion Reducing stigma associated with mental illness is an important aim of medical education, yet evidence suggests that senior students have worse attitudes toward patients with mental-health disorders than more-junior students, in particular, worse attitudes toward patients with unexplained medical symptoms. Students background and culture need to be taken into account in developing educational resources addressing stigma.
We are grateful to Nishan Dharmaindra for his input into the design and analysis of this study.

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